Linear Projection of Estimated Glomerular Filtration Rate Decline with Canagliflozin and Implications for Dialysis Utilization and Cost in Diabetic Nephropathy

Prevalence of diabetes mellitus and dialysis risk based on annual health checkup frequency among National Health Insurance citizens in Japan

BACKGROUND

In Japan, type 2 diabetes mellitus (T2DM) is a major health concern due to its increasing prevalence and associated complications, including diabetic nephropathy and dialysis. Although the positive relationship between annual health checkups and health outcomes is well-documented, the impact of skipping health checkups on T2DM and its progression to dialysis remains unclear. This study aimed to explore the association between the frequency of annual health checkups and DM-related indices and the potential impact of early intervention in preventing dialysis.

METHODS

The study included citizens aged ≥ 40 years from Nobeoka City, Japan (n = 22,094). Health checkup data from 2021 were analyzed, and participants were categorized into four groups based on their health checkup attendance between 2018 and 2020. Logistic regression analyses evaluated the association between health checkup frequency and DM-related indices, such as hemoglobin A1c and estimated glomerular filtration rate. These indices are used to diagnose DM and evaluate its severity. The time to dialysis for citizens without health checkups was estimated under untreated and treated scenarios using a previously published model.

RESULTS

Among the 3,472 participants who underwent health checkups in 2021, 2,098 (60.4%) were women, and 1,374 (39.6%) were men. Citizens who missed health checkups for 3 consecutive years had a higher risk of T2DM than those who had annual checkups (odds ratio = 4.69, 95% confidence interval: 2.78-7.94). No significant difference was observed in T2DM rates between those who attended once or twice and those who attended annually. Simulations for high-risk citizens showed that 32 of 39 individuals may require dialysis during their lifetime; however, early intervention could prevent dialysis in 31 of them.

CONCLUSIONS

Citizens who skipped health checkups for 3 consecutive years or longer had a higher risk of T2DM, highlighting the need for targeted public interventions to prevent DM in this population.

SGLT2 inhibitors for patients with type 2 diabetes and CKD: a narrative review

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have recently emerged as an effective means to protect kidney function in people with type 2 diabetes and chronic kidney disease (CKD). In this review, we explore the role of SGLT2 inhibition in these individuals. SGLT2 inhibitors specifically act to inhibit sodium and glucose reabsorption in the early proximal tubule of the renal nephron. Although originally developed as glucose-lowering agents through their ability to induce glycosuria, it became apparent in cardiovascular outcome trials that the trajectory of kidney function decline was significantly slowed and the incidence of serious falls in kidney function was reduced in participants receiving an SGLT2 inhibitor. These observations have recently led to specific outcome trials in participants with CKD, including DAPA-CKD, CREDENCE and EMPA-KIDNEY, and real-world studies, like CVD-REAL-3, that have confirmed the observation of kidney benefits in this setting. In response, recent KDIGO Guidelines have recommended the use of SGLT2 inhibitors as first-line therapy in patients with CKD, alongside statins, renin-angiotensin-aldosterone system inhibitors and multifactorial risk factor management as indicated. However, SGLT2 inhibitors remain significantly underutilized in the setting of CKD. Indeed, an inertia paradox exists, with patients with more severe disease less likely to receive an SGLT2 inhibitor. Concerns regarding safety appear unfounded, as acute kidney injury, hyperkalaemia, major acute cardiovascular events and cardiac death in patients with CKD appear to be lower following SGLT2 inhibition. The first-in-class indication of dapagliflozin for CKD may begin a new approach to managing kidney disease in type 2 diabetes.

Findings of Sodium-Glucose Cotransporter-2 Inhibitor Kidney Outcome Trials Applied to a Canadian Chronic Kidney Disease Population: A Retrospective Cohort Study

Background

The canagliflozin and renal endpoints in diabetes with established nephropathy clinical evaluation (CREDENCE) and dapagliflozin and prevention of adverse outcomes in chronic kidney disease (DAPA-CKD) trials have demonstrated significant kidney benefits with sodium-glucose cotransporter-2 (SGLT2) inhibitors. SGLT2 inhibitors are now standard of care for patients with diabetic kidney disease and have also been shown to be effective in those with albuminuric CKD with or without diabetes.

Objective

We sought to determine how many patients in nephrology care in British Columbia, Canada, would have been eligible for those trials, to compare rates of outcomes, and to estimate cost avoidance arising from widespread use of SGLT2 inhibitors in this cohort.

Study design

Retrospective cohort study.

Setting

British Columbia, Canada.

Participants

CKD patients followed in the Kidney Care Clinics in British Columbia.

Measurements

We compared the outcomes of kidney failure, sustained estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m², dialysis, transplant, death from any cause, and doubling of serum creatinine. We also compared the composite outcome of kidney failure and doubling of serum creatinine.

Methods

The cohort was derived using a provincial database by combining the inclusion criteria of CREDENCE and DAPA-CKD trials. We included adult patients aged ≥18 years, urine albumin to creatinine ratio (UACR) ≥20 mg/mmol, and eGFR between 25 and 90 mL/min/1.73 m², between April 1, 2014 and March 31, 2017. The primary outcome was compared with the outcomes experienced in the placebo arms of CREDENCE and DAPA-CKD. The composite outcome stratified by eGFR categories were compared in the British Columbia cohort and the CREDENCE trial. Cost avoidance was estimated based on the number needed to treat to prevent one instance of kidney failure.

Results

A total of 17.5% (3138/17 963) of patients were eligible, resulting in a cohort with a mean age of 69.7 years and 38% women. The eGFR slope of the British Columbia cohort was -4.21 ± 0.47 mL/min. The mean eGFR was 37.0 mL/min/1.73 m², median UACR was 55.3 mg/mmol, and use of renin-angiotensin-aldosterone system inhibitors was 56.6%. The British Columbia cohort experienced nearly double the outcomes of kidney failure, death from any cause, and doubling of serum creatinine than the placebo arms of CREDENCE and DAPA-CKD. When stratified by eGFR, the British Columbia cohort and the CREDENCE placebo arm had similar event rates for those with an eGFR <45 mL/min but there were still higher rates of outcome in the greater than 45 mL/min eGFR groups in the British Columbia cohort. Treating the British Columbia cohort with canagliflozin could lead to net cost avoidance of $2.31 million over 2.6 years.

Limitations

The database only captures those referred to the Kidney Care Clinics by nephrologists, which may lead to selection bias of higher risk patients in the British Columbia cohort. The cost avoidance analysis was a limited high-level analysis.

Conclusions

The British Columbia cohort represents a high-risk group in whom implementation of the use of SGLT2 inhibitors may well improve outcomes and reduce health care system costs.

Modeling Chronic Kidney Disease in Type 2 Diabetes Mellitus: A Systematic Literature Review of Models, Data Sources, and Derivation Cohorts

INTRODUCTION

As novel therapies for chronic kidney disease (CKD) in type 2 diabetes mellitus (T2DM) become available, their long-term benefits should be evaluated using CKD progression models. Existing models offer different modeling approaches that could be reused, but it may be challenging for modelers to assess commonalities and differences between the many available models. Additionally, the data and underlying population characteristics informing model parameters may not always be evident. Therefore, this study reviewed and summarized existing modeling approaches and data sources for CKD in T2DM, as a reference for future model development.

METHODS

This systematic literature review included computer simulation models of CKD in T2DM populations. Searches were implemented in PubMed (including MEDLINE), Embase, and the Cochrane Library, up to October 2021. Models were classified as cohort state-transition models (cSTM) or individual patient simulation (IPS) models. Information was extracted on modeled kidney disease states, risk equations for CKD, data sources, and baseline characteristics of derivation cohorts in primary data sources.

RESULTS

The review identified 49 models (21 IPS, 28 cSTM). A five-state structure was standard among state-transition models, comprising one kidney disease-free state, three kidney disease states [frequently including albuminuria and end-stage kidney disease (ESKD)], and one death state. Five models captured CKD regression and three included cardiovascular disease (CVD). Risk equations most commonly predicted albuminuria and ESKD incidence, while the most predicted CKD sequelae were mortality and CVD. Most data sources were well-established registries, cohort studies, and clinical trials often initiated decades ago in predominantly White populations in high-income countries. Some recent models were developed from country-specific data, particularly for Asian countries, or from clinical outcomes trials.

CONCLUSION

Modeling CKD in T2DM is an active research area, with a trend towards IPS models developed from non-Western data and single data sources, primarily recent outcomes trials of novel renoprotective treatments.

Sodium Glucose Transporter, Type 2 (SGLT2) Inhibitors (SGLT2i) and Glucagon-Like Peptide 1-Receptor Agonists: Newer Therapies in Whole-Body Glucose Stabilization

Diabetes is a worldwide epidemic that is increasing rapidly to become the seventh leading cause of death in the world. The increased incidence of this disease mirrors a similar uptick in obesity and metabolic syndrome, and, collectively, these conditions can cause deleterious effects on a number of organ systems including the renal and cardiovascular systems. Historically, treatment of type 2 diabetes has focused on decreasing hyperglycemia and glycated hemoglobin levels. However, it now is appreciated that there is more to the puzzle. Emerging evidence has indicated that newer classes of diabetes drugs, sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1-receptor agonists, improve cardiovascular and renal function, while appropriately managing hyperglycemia. In this review, we highlight the recent clinical and preclinical studies that have shed light on sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1-receptor agonists and their ability to stabilize blood glucose levels while offering whole-body protection in diabetic and nondiabetic patient populations.