Dapagliflozin and Blood Pressure in Patients with Chronic Kidney Disease and Albuminuria

The effects of empagliflozin on systemic haemodynamic function: three randomized, placebo-controlled trials

BACKGROUND

Sodium glucose cotransporter 2 inhibitors lower blood pressure. The underlying mechanisms are multifactorial and include effects on vascular function. We examined the systemic hemodynamic effects of empagliflozin in patients with type 2 diabetes mellitus (DM2) with and without chronic kidney disease (CKD) and in patients with nondiabetic CKD.

METHODS

Three double-blinded, randomized, placebo-controlled cross-over trials, including patients with DM2 and preserved renal function ( n  = 16), DM2 and CKD ( n  = 17) and nondiabetic CKD ( n  = 16). Participants were randomized to 4 weeks of empagliflozin 10 mg or placebo and crossed over after a 2-week washout. We measured brachial and central 24-h ambulatory blood pressure (ABP), pulse wave velocity (PWV), augmentation index (AIx@75), markers of nitric oxide and erythrocyte sodium sensitivity (ESS), a marker of endothelial glycocalyx function.

RESULTS

Empagliflozin reduced PWV [-0.16 m/s, 95% confidence interval (95% CI): -0.26; -0.06, P  = 0.002], AIx@75 (-2.17%, 95% CI: -3.31; -1.02, P  < 0.001) and brachial and central ABP in the combined study population ( n  = 49). Changes in PWV and AIx@75 correlated to changes in systolic brachial ABP. Markers of nitric oxide did not increase, but empagliflozin decreased ESS, which was correlated to an increase in haematocrit.

CONCLUSION

Empagliflozin decreased arterial stiffness, mediated partly by a decrease in brachial ABP. We found no increase in nitric oxide activity, but ESS decreased. While this may be explained partly by a change in haematocrit, it could indicate an improvement in endothelial glycocalyx function.

TRIAL REGISTRATION

EU Clinical Trials Register 2019-004303-12, 2019-004447-80 and 2019-004467-50.

Dapagliflozin prevents vascular ischemia-reperfusion injury in healthy young males: a randomized, placebo-controlled, double-blinded trial

Ischemia-reperfusion injury (IRI) causes vascular endothelial dysfunction. Preclinical data suggest that the SGLT2 inhibitor dapagliflozin may protect against vascular IRI. This trial has investigated if oral treatment with dapagliflozin can mitigate the transient impairment of IRI-induced-endothelial dysfunction in the forearm resistance vasculature. 32 healthy males (n = 16 per group, age: 27 ± 4 yrs) were studied in this randomized, placebo-controlled, parallel-group, double-blinded trial. Acetylcholine (ACh; endothelium-dependent vasodilator) and glyceryltrinitrate (GTN; endothelium-independent vasodilator) were administered into the brachial artery of the non-dominant arm. The response to stepwise increasing doses on forearm blood flow (FBF) was assessed. FBF was measured before and after a cuff-induced 20-minute forearm ischemia at pre-dose and following daily intake of 10 mg dapagliflozin or placebo over 15 days. IRI reduced endothelium-dependent vasodilatation by 29% (p < 0.001, paired t-test). After a 15-day treatment period, IRI-induced endothelial dysfunction was abrogated in participants receiving dapagliflozin (FBF AChAUC ratios post- vs. pre-ischemia: dapagliflozin: 0.93; 95% CI: 0.80-1.29) but unchanged with placebo (0.81; 95% CI: 0.68-0.92; p = 0.015 vs. pre-ischemia). GTN-induced vasodilation was not altered by IRI or treatment. Dapagliflozin treatment at standard clinical doses over 15 days prevents IRI-induced vascular endothelial dysfunction in the forearm resistance vasculature of healthy young males. The underlying mechanism and the potential clinical impact remain to be demonstrated.Clinical trial registration https://clinicaltrials.gov/study/NCT05217654 NCT05217654; EudraCT number: 2021-005002-95 Date of registration: 20/01/2022.

Efficacy and safety of dapagliflozin in patients with CKD: real-world experience in 93 Italian renal clinics

Background

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are recommended for reducing the renal and cardiovascular risk in patients with chronic kidney disease (CKD) based on the positive results reported by clinical trials. However, real-world data on the efficacy and the safety of these drugs in CKD population followed in nephrology setting are lacking.

Methods

We report the effects of dapagliflozin in CKD patients by using data collected during a learning program in which 105 nephrologists added dapagliflozin (10 mg/day) to consecutive patients referred to their renal clinics. Efficacy endpoints were the albuminuria change and the determinants of an albuminuria decline ≥30%. Adverse events were also collected.

Results

A total of 1724 patients with CKD (age 67.4 ± 13.2 years, 72.8% males, diabetes 59.9%, eGFR 43.5 ± 17.4 ml/min/1.73 m2, severe albuminuria 70.1%) received dapagliflozin for 4 ± 1 months. Dapagliflozin significantly reduced body weight (-1.3 kg), eGFR (-0.27 ml/min/month), and blood pressure (-3.6/-1.7 mmHg). Albuminuria declined by 25.1% (95%CI 23.0-27.2) from 500 mg/day [IQR 225-1425] to 320 mg/day [IQR 100-900]. Albuminuria reduction was ≥30% in 48.3% of patients, 0-29% in 37.6% while it increased in 14.1% of patients. At logistic regression analysis, older age, female sex, use of mineralocorticoid receptor antagonist, higher eGFR, and higher albuminuria were all significant predictors of albuminuria decline ≥30%. We collected 46 side effects leading to drug discontinuation in 36 patients (2%), with acute kidney injury and urinary tract infection being the most frequent adverse events.

Conclusions

We provide evidence of the anti-proteinuric efficacy of short-term dapagliflozin in the presence of good safety profile in patients with CKD followed in nephrology.

Randomized, Placebo-Controlled Trial on the Renal and Systemic Hemodynamic Effects of Empagliflozin

Introduction

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve renal outcomes in type 2 diabetes mellitus (DM2) and chronic kidney disease (CKD). A decrease in renal blood flow (RBF) with attenuation of glomerular hyperfiltration may contribute. We examined renal and systemic hemodynamic effects of SGLT2i in relevant patient categories.

Methods

Using a double-blind placebo controlled cross-over design, we randomized patients with DM2 and estimated glomerular filtration rate (eGFR) > 60 ml/min per 1.73 m2 (n = 16), patients with DM2 and eGFR from 20 to 60 ml/min per 1.73 m2 (n = 17), and patients with nondiabetic CKD and eGFR from 20 to 60 ml/min per 1.73 m2 (n = 16) to empagliflozin 10 mg daily or placebo for 4 weeks and crossed over to the opposite treatment after 2-week washout. RBF was measured with 82Rubidium-positron emission-tomography/computed-tomography, glomerular filtration rate (GFR) with 99mTechnetium-diethylene-triamine-pentaacetate-clearance. A Mobil-O-graph was used to record 24-hour blood pressure (BP) and total vascular resistance (TVR).

Results

Compared to placebo, empagliflozin reduced RBF by 6% in the DM2-CKD group (P < 0.001) with nonsignificant decreases of 4% in the DM2 group and 1% in the CKD group (P = 0.29 and 0.72, respectively). Empagliflozin reduced GFR, BP, and TVR in all groups, whereas renal vascular resistance (RVR) remained unchanged.

Conclusion

Empagliflozin reduced RBF in patients with DM2 and CKD, whereas GFR, BP, and TVR were reduced in all groups. This pattern, together with a lack of reduction in RVR, suggests SGLT2i protect the glomerulus through combined preglomerular and post glomerular effects.