Glucagon-like peptide 1 receptor agonists in end-staged kidney disease and kidney transplantation: A narrative review

Cystic Fibrosis and Hemochromatosis Carriers May Be Prone to Glucagon-like Peptide-1 Agonist Pancreatitis: 3 Cases

Glucagon-like peptide-1 (GLP-1) agonists are widely used in the management of type 2 diabetes and obesity, with their therapeutic scope expanding to address cardiometabolic and cardiorenal conditions. However, their increasing use has been associated with potential adverse effects, including acute pancreatitis (AP). The exact prevalence of GLP-1 agonist-induced AP remains uncertain and reliable predictors for its onset have yet to be identified. We present 3 cases of class-associated predilection for GLP-1 analog-associated AP in patients with carrier states for hemochromatosis (HC) and cystic fibrosis. Case 1 is a heterozygous carrier for the C282Y HC pathogenic variant. Case 2 is a heterozygous carrier of the Delta F508 deletion of the cystic fibrosis transmembrane regulator (CFTR) gene. Case 3 is compound heterozygous carrier of a single CFTR intron 9 poly T allele pathogenic variant (5T/7T/8T), as well as a single pathogenic variant of the C282Y HC gene. Our observation suggests that carrier states for cystic fibrosis and HC may predispose individuals to GLP-1 agonist-associated AP. Genetic testing for these carrier states should be considered among patients with GLP-1 agonist-associated AP to provide more support and data for this as a potential true risk factor.

Glucagon-like peptide-1 receptor agonists to improve cardiorenal outcomes: data from FLOW and beyond

PURPOSE OF REVIEW

Glucagon-like peptide-1 receptor agonists (GLP1RA), initially approved for glycemic control in type 2 diabetes mellitus (T2DM), have emerged as agents for weight loss, cardiovascular and kidney protection. This review summarizes the evidence supporting the benefits of these therapies on cardiorenal outcomes.

RECENT FINDINGS

Clinical trials have consistently demonstrated reductions in major adverse cardiovascular events with GLP1RA treatments. Recently, the FLOW trial revealed that semaglutide reduced the composite outcome of kidney failure, at least 50% decline in estimated glomerular filtration rate, kidney or cardiovascular mortality by 24% in patients with T2DM, thereby establishing GLP1RA as a pillar of therapy in this population. New evidence suggests favorable effects on kidney endpoints in nondiabetic individuals with overweight or obesity. Dedicated trials have also provided evidence for reduction in the risk for heart failure hospitalization and improvement in symptoms in individuals with heart failure with preserved ejection fraction. Subgroup analyses have suggested that GLP1RAs confer additive cardiorenal benefits irrespective of background medication use.

SUMMARY

There is increasing evidence that GLP1RA reduces the risk for cardiovascular events, chronic kidney disease progression, and heart failure hospitalizations. Further data on the effect of dual and triple GLP1-based therapies on cardiorenal outcomes is required.

Patients With Severe Obesity Are Made Eligible for Complex Abdominal Wall Repair After Preoptimization With GLP-1 Agonists: Results of a Bicentric Pilot Study

BACKGROUND

Incisional hernia repairs (IHRs) are not recommended in patients with severe obesity (BMI ≥ 35 kg/m2). Weight loss is challenging, but new medications, such as glucagon-like peptide-1 receptor agonists (GLP-1 agonists), have recently attracted increased attention for their potential weight loss advantages. The aim was to analyze the preliminary results about the safety and weight loss efficiency of the use of GLP-1 agonists in the context of prehabilitation prior to complex IHR.

METHODS

All patients planned for IHR with a BMI ≥ 35 kg/m2 and treated with preoperative GLP-1 agonists were included in the experimental group and compared with a comparable historical surgical cohort treated with a conventional tailored nutritional preoperative management. Weight loss in the experimental group and perioperative and postoperative outcomes were compared between the two groups. The success rate of GLP1 agonists was defined as a weight loss that enables the patient to fall within the recommended limits of a BMI ≤ 35 kg/m2 before an IHR.

RESULTS

Fifty-two patients in the control group were compared to 24 with GLP-1 agonists. The distribution of GLP-1 agonists was as follows: semaglutide (n = 12; 50%), dulaglutide (n = 7; 29.2%), and liraglutide (n = 5; 20.8%). The mean initial BMI was 40.1 ± 3.6 kg/m2 kg/m2. The average percentage of weight loss was 11.3 ± 7.4% with GLP-1 agonists (maximum weight loss was observed with semaglutide 2.4 mg/wk). The success rate of GLP1 agonists (defined as BMI ≤ 35 kg/m2 before IHR) was reached for 15/24 patients (62.5%). Postoperative total complication rate was lower in the group with GLP-1 agonists (59.6% in the control group vs. 45.8% in GLP-1 and p = 0.2).

CONCLUSION

This study demonstrated the efficacy of GLP-1 agonists in the optimization of patients with obesity, allowing two thirds of the patients to benefit from IHR, with a tendency for lower morbidity.

TRIAL REGISTRATION

CPP Mediterranee, n° 21.00430.000004.

The Real-World Use of Semaglutide to Promote Weight Loss in Obese Adults With Hemodialysis: A Multicenter Cross-Sectional Descriptive Study

Background

Obesity can be an issue for renal transplant eligibility. Semaglutide constitutes an interesting choice for obesity treatment, but little data exist regarding its efficacy and security among dialysis patients.

Objectives

The co-primary endpoints of this study were to describe the change in body weight (%) and in body mass index (BMI) from the beginning and after 3, 6, and 12 months of treatment for participants who used semaglutide compared with a control group of non-users. Secondary endpoints included description of dosages used and reported adverse events.

Design

Multicenter cross-sectional descriptive study.

Setting

Seven hemodialysis centers in Quebec and New Brunswick, Canada.

Patients

Adults receiving hemodialysis treatment with BMI of at least 30 kg/m2 were included.

Measurements

Weight as defined by the target body weight (kg) at the end of dialysis. Body mass index is defined by weight, kg/m2.

Methods

As a primary objective, we collected in records the body weights and calculated BMI at months 0, 3, 6, and 12 for participants with BMI of 30 kg/m2 or greater. The dosages of semaglutide and the mention of any adverse events were also collected from questionnaire to participants, to community drug stores, and from records.

Results

A total of 1286 patients received hemodialysis treatments in June 2023. Of these, 396 (31%) had a BMI of 30 kg/m2 or greater. Two hundred fifty-one participants were included in the study and 41 (16%) received semaglutide. The estimated treatment differences for the percentage change in body weight from baseline to 3, 6, and 12 months for semaglutide compared with the control group were -2.26%, 95% confidence interval (CI), -3.68 to -0.84, P = .002; -0.94%, 95% CI, -2.17 to 0.29, P = 0.135; and -0.64%; 95% CI, -2.04 to 0.76, P = .370, respectively. The estimated treatment differences at 3, 6, and 12 months for BMI were -0.87 kg/m2, 95% CI, -1.38 to -0.36, P < .001; -0.35 kg/m2, 95% CI, -0.79 to 0.09, P = .119; and -0.23 kg/m2, 95% CI, -0.72 to 0.27, P = .371, respectively. The estimated treatment difference in body weight and BMI change between the 2 groups was statistically significant at 3 months. A sensitivity analysis was carried out with all the participants of the semaglutide group who continued the treatment for 12 months (N = 15). The estimated treatment differences for the percentage change in body weight between this group and the control group were -3.04%, 95% CI, -5.18 to -0.89, P = .006; -1.97%, 95% CI, -3.79 to -0.14, P = .035; and -2.83%, 95% CI, -4.66 to -1.00, P = .003 at 3, 6, and 12 months, respectively. The average body weight change between months 0 and 12 was -3.88 ± 7.90 kg in the semaglutide group compared with -0.52 ± 5.53 kg in the control group (P = .015). With the sensitivity analysis, the body weight change between Months 0 and 12 was -6.83 ± 6.90 kg for the participants who continued their treatment for 12 months. The dosage of 1 mg of semaglutide was the most prescribed (49%). The occurrence of adverse events led to dose reduction in 5 participants (12%) and to treatment discontinuation in 13 participants (32%).

Limitations

This study has several limitations, including its non-randomized design, short follow-up period, small sample size, and incomplete data on treatment compliance and adverse effects. Differences in patient characteristics, limited semaglutide doses for weight loss, and declining sample sizes over time further reduce the strength of conclusions, necessitating cautious interpretation of group comparisons.

Conclusions

This study suggests that semaglutide promotes weight loss in hemodialyzed adults with obesity, but discontinuation of treatment was frequent and common adverse events were reported.

Benefits of Glucagon-like Peptide-1 Receptor Agonists After Kidney Transplantation

OBJECTIVE

Benefits of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in kidney transplant (KT) recipients have not been adequately studied.

METHODS

We retrospectively examined the effects of GLP-1 RA on mortality, kidney outcomes and metabolic parameters in KT recipients with type 2 diabetes mellitus (T2DM) treated versus not treated with GLP-1 RA. A reference group of KT recipients not treated with GLP-1 RA was used for comparison. Data were analyzed using analysis of variance, χ2 tests, and generalized estimating equation models. GLP-1 RA was used as a time-dependent model in Cox regression modeling. For survival analysis, the final model fitting was stratified by race-ethnicity.

RESULTS

Seventy-seven KT recipients with T2DM were treated with GLP-1 RA for at least 12 months. Reference group included 2094 patients not on GLP-1 RA. The mean (SD) age at transplant was 57.9 (9.5) and 60.8 (9.5) years for the treatment and reference groups, respectively. Median follow-up time from the index date for mortality was 1.5 (IQR 0.99, 2.4) in the treatment and 5.8 (IQR 3.4, 9.1) years in the reference group. GLP-1 RA use was associated with improved survival (P = .049), decreased urine albumin to creatinine ratio (net reduction of 10.62 mg/g per year, P = .003), slower estimated glomerular filtration rate decline (1.04 vs 1.56 mL/min/1.73 m2 per year, P = .04), and lower troponin levels.

CONCLUSIONS

GLP-1 RA in KT recipients with T2DM was associated with reduced mortality, and improved kidney function compared to the reference group. Larger, prospective studies are needed to fully evaluate the risks and benefits of GLP-1 RA therapy in KT recipients.

Glycemic Management and Individualized Diabetes Care in Dialysis-Dependent Kidney Failure

Of the nearly 600,000 people in the U.S. who receive dialysis for chronic kidney failure, >60% have diabetes. People receiving dialysis who have diabetes have worse overall and cardiovascular survival rates than those without diabetes. Diabetes care in the dialysis setting is complicated by kidney failure-related factors that render extrapolation of glycated hemoglobin (HbA1c) targets to the dialysis population unreliable and may change the risk-benefit profiles of glucose-lowering and disease-modifying therapies. No prospective studies have established the optimal glycemic targets in the dialysis population, and few randomized clinical trials of glucose-lowering medications included individuals receiving dialysis. Observational data suggest that both lower and higher HbA1c are associated with mortality in the dialysis population. Existing data suggest the potential for safety and effectiveness of some glucose-lowering medications in the dialysis population, but firm conclusions are hindered by limitations in study design and sample size. While population-specific knowledge gaps about optimal glycemic targets and diabetes medication safety and effectiveness preclude the extension of all general population diabetes guidelines to the dialysis-dependent diabetes population, these uncertainties should not detract from the importance of providing person-centered diabetes care to people receiving dialysis. Diabetes care for individuals with and without dialysis-dependent kidney failure should be holistic, based on individual preferences and prognoses, and tailored to integrate established treatment approaches with proven benefits for glycemic control and cardiovascular risk reduction. Additional research is needed to inform how recent pharmacologic and technological advances can be applied to support such individualized care for people receiving maintenance dialysis.

Pharmacological Nephroprotection in Chronic Kidney Disease Patients with Type 2 Diabetes Mellitus-Clinical Practice Position Statement of the Polish Society of Nephrology

Both chronic kidney disease (CKD) and type 2 diabetes (T2D) are modern epidemics worldwide and have become a severe public health problem. Chronic kidney disease progression in T2D patients is linked to the need for dialysis or kidney transplantation and represents the risk factor predisposing to serious cardiovascular complications. In recent years, important progress has occurred in nephroprotective pharmacotherapy in CKD patients with T2D. In the current position paper, we described a nephroprotective approach in CKD patients with T2D based on the five following pillars: effective antihyperglycemic treatment, SGLT2 inhibitor or semaglutide, antihypertensive therapy, use of RASi (ARB or ACEi), and in selected patients, finerenone, as well as sodium bicarbonate in patients with metabolic acidosis. We thought that the current statement is comprehensive and up-to-date and addresses multiple pathways of nephroprotection in patients with CKD and T2D.

GLP-1 Agonism for Kidney Transplant Recipients: A Narrative Review of Current Evidence and Future Directions Across the Research Spectrum

Purpose of Review

Diabetes is the most common cause of kidney disease in individuals that receive a kidney transplant, and those without pre-existing diabetes are at greater risk of developing diabetes following kidney transplant. A class of diabetes treatment medications called glucagon-like peptide-1 receptor agonists (GLP-1RA) has seen recent widespread use for people with diabetes or obesity, with efficacy for improved glycemic control, weight loss, and reduced risk of cardiovascular events. Given these benefits, and indications for use that often co-occur in kidney transplant recipients, use of GLP-1RAs warrants consideration in this population. Therefore, we sought to review the current literature to better understand the mechanisms of action, clinical application, and person-centred considerations of GLP-1RAs in kidney transplant recipients.

Sources of Information

Original articles were identified between December 2023 and July 2024 from electronic databases including the Ovid MEDLINE database, PubMed, and Google Scholar using terms "kidney transplant," "GLP-1," "glucagon-like peptide-1 receptor agonist," and "diabetes."

Methods

A comprehensive review of the literature was conducted to explore the relationship between GLP-1RAs and kidney transplant recipients. We reviewed the current state of evidence across the research disciplines of basic or fundamental science, clinical and health services research, and person-centred equity science, and highlighted important knowledge gaps that offer opportunities for future research.

Key Findings

Numerous clinical studies have demonstrated the benefit of GLP-1RAs in people with and without diabetic kidney disease, including decreased risk of cardiovascular events. However, there is a paucity of high-quality randomized controlled trials and observational studies analyzing use of GLP-1RAs in kidney transplant recipients. Evidence of benefit in this population is therefore limited to small studies or inferred from research conducted in nontransplant populations. Growing evidence from preclinical and clinical studies may elucidate renoprotective mechanisms of GLP-1RAs and remove barriers to application of these drugs in the transplant recipient population. Individuals who are female, non-white, have lower socioeconomic status, and live in rural communities are at greater risk of diabetes and have lower uptake of GLP-1RAs. There is a need for clinical trials across diverse kidney transplant populations to estimate the efficacy of GLP-1RAs on important health outcomes.

Limitations

The search strategy for this narrative review may not have been sensitive to identify all relevant articles. Our search was limited to English language articles.

Obesity, organ failure, and transplantation: A review of the role of metabolic and bariatric surgery in transplant candidates and recipients

Obesity is a risk factor for kidney, liver, heart, and pulmonary diseases, as well as failure. Solid organ transplantation remains the definitive treatment for the end-stage presentation of these diseases. Among many criteria for organ transplant, efficient management of obesity is required for patients to acquire transplant eligibility. End-stage organ failure and obesity are 2 complex pathologies that are often entwined. Metabolic and bariatric surgery before, during, or after organ transplant has been studied to determine the long-term effect of bariatric surgery on transplant outcomes. In this review, a multidisciplinary group of surgeons from the Society of American Gastrointestinal and Endoscopic Surgeons and the American Society for Transplant Surgery presents the current published literature on metabolic and bariatric surgery as a therapeutic option for patients with obesity awaiting solid organ transplantation. This manuscript details the most recent recommendations, pharmacologic considerations, and psychological considerations for this specific cohort of patients. Since level one evidence is not available on many of the topics covered by this review, expert opinion was implemented in several instances. Additional high-quality research in this area will allow for better recommendations and, therefore, treatment strategies for these complex patients.

Kidney Transplant Candidacy: Addressing Common Medical and Psychosocial Barriers to Transplant

Improving access to kidney transplants remains a priority for the transplant community. However, many medical, psychosocial, geographic, and socioeconomic barriers exist that prevent or delay transplantation for candidates with certain conditions. There is a lack of consensus regarding how to best approach many of these issues and barriers, leading to heterogeneity in transplant centers' management and acceptance practices for a variety of pretransplant candidate issues. In this review, we address several of the more common contemporary patient medical and psychosocial barriers frequently encountered by transplant programs. The barriers discussed here include kidney transplant candidates with obesity, older age, prior malignancy, cardiovascular disease, history of nonadherence, and cannabis use. Improving understanding of how to best address these specific issues can empower referring providers, transplant programs, and patients to address these issues as necessary to progress toward eventual successful transplantation.

Obesity, organ failure, and transplantation: a review of the role of metabolic and bariatric surgery in transplant candidates and recipients

Obesity is a risk factor for kidney, liver, heart, and pulmonary diseases, as well as failure. Solid organ transplantation remains the definitive treatment for the end-stage presentation of these diseases. Among many criteria for organ transplant, efficient management of obesity is required for patients to acquire transplant eligibility. End-stage organ failure and obesity are 2 complex pathologies that are often entwined. Metabolic and bariatric surgery before, during, or after organ transplant has been studied to determine the long-term effect of bariatric surgery on transplant outcomes. In this review, a multidisciplinary group of surgeons from the Society of American Gastrointestinal and Endoscopic Surgeons and the American Society for Transplant Surgery presents the current published literature on metabolic and bariatric surgery as a therapeutic option for patients with obesity awaiting solid organ transplantation. This manuscript details the most recent recommendations, pharmacologic considerations, and psychological considerations for this specific cohort of patients. Since level one evidence is not available on many of the topics covered by this review, expert opinion was implemented in several instances. Additional high-quality research in this area will allow for better recommendations and, therefore, treatment strategies for these complex patients.

Mortality and cardiovascular events in diabetes mellitus patients at dialysis initiation treated with glucagon-like peptide-1 receptor agonists

BACKGROUND

Glucagon-like Peptide-1 Receptor Agonists (GLP-1RAs) have demonstrated efficacy in improving mortality and cardiovascular (CV) outcomes. However, the impact of GLP-1RAs therapy on cardiorenal outcomes of diabetic patients at the commencement of dialysis remains unexplored.

PURPOSE

This study aimed to investigate the long-term benefits of GLP-1RAs in type 2 diabetic patients at dialysis commencement.

METHODS

A cohort of type 2 diabetic patients initializing dialysis was identified from the TriNetX global database. Patients treated with GLP-1RAs and those treated with long-acting insulin (LAI) were matched by propensity score. We focused on all-cause mortality, four-point major adverse cardiovascular events (4p-MACE), and major adverse kidney events (MAKE).

RESULTS

Among 82,041 type 2 diabetic patients initializing dialysis, 2.1% (n = 1685) patients were GLP-1RAs users (mean ages 59.3 years; 55.4% male). 1682 patients were included in the propensity-matched group, treated either with GLP-1RAs or LAI. The main causes of acute dialysis in this study were ischemic heart disease (17.2%), followed by heart failure (13.6%) and sepsis (6.5%). Following a median follow-up of 1.4 years, GLP-1RAs uses at dialysis commencement was associated with a reduced risk of mortality (hazard ratio [HR] = 0.63, p < 0.001), 4p-MACE (HR = 0.65, p < 0.001), and MAKE (HR = 0.75, p < 0.001). This association was particularly notable in long-acting GLP-1RAs users, with higher BMI, lower HbA1c, and those with eGFR > 15 ml/min/1.73m2. GLP-1RAs' new use at dialysis commencement was significantly associated with a lower risk of MACE (p = 0.047) and MAKE (p = 0.004). Additionally, GLP-1RAs use among those who could discontinue from acute dialysis or long-term RAs users was associated with a lower risk of mortality, 4p-MACE, and MAKE.

CONCLUSION

Given to the limitations of this observational study, use of GLP-1RAs at the onset of dialysis was associated with a decreased risk of MACE, MAKE, and all-cause mortality. These findings show the lack of harm associated with the use of GLP-1RAs in diabetic patients at the initiation of acute dialysis.

Safety and efficacy of semaglutide in post kidney transplant patients with type 2 diabetes or Post-Transplant diabetes

Objective

Type 2 diabetes mellitus (T2DM) and post-transplant diabetes mellitus (PTDM) are common in renal transplant recipients. Semaglutide has demonstrated efficacy and safety in patients with T2DM. To date, only a limited number of studies have investigated its use in renal transplant patients. This study assessed the safety and efficacy of semaglutide in post-renal transplant patients.

Methods

A retrospective study was conducted at king Abdulaziz Medical City-Riyadh, Saudi Arabia. The subjects of the study were adults and adolescents (>14 years) who had undergone a kidney transplant and had pre-existing T2DM or PTDM. The study subjects were given semaglutide during the study period, from January 2018 to July 2022. The data were collected over a period of 18 months.

Results

A total of 39 patients were included, 29 (74 %) of whom were male. A significant decrease in hemoglobin A1c (HbA1c) was observed during the follow-up period when compared to baseline (8.4 %±1.3 % at baseline vs. 7.4 %±1.0 % at 13-18 months (p < 0.001). A significant reduction in weight was also noted at follow-up as compared to baseline (99.5 kg ± 17.7 vs 90.7 kg ± 16.8 at 13-18 months (p < 0.001). No significant changes were found in renal graft function markers.

Conclusion

Semaglutide was found to significantly reduce HbA1c levels and weight in post renal transplant patients with diabetes. No significant changes in markers of renal graft function were observed.

Home-Based Dialysis: A Primer for the Internist

Home-based dialysis modalities offer both clinical and practical advantages to patients. The use of the home-based modalities, peritoneal dialysis and home hemodialysis, has been increasing over the past decade after a long period of decline. Given the increasing frequency of use of these types of dialysis, it is important for clinicians to be familiar with how these types of dialysis are performed and key clinical aspects of care related to their use in patients with end-stage kidney disease.

Injectable Weight Loss Medications in Plastic Surgery: What We Know, Perioperative Considerations, and Recommendations for the Future

Obesity is a major epidemic plaguing American society. Injectable subcutaneous medications initially designed for use in type 2 diabetes management, such as semaglutide and other glucagon-like peptide-1 receptor agonists, are rapidly gaining popularity for their effects on weight. These drugs (Ozempic, Wegovy, Saxenda, and Mounjaro) are ubiquitous on social media and are promoted by celebrities across all demographics. "Ozempic face" and "Ozempic butt" are now mainstream concepts highlighting the morphologic changes that occur with these medications. There is a paucity of literature available on the impact of these medications for plastic surgeons and their patients. As use becomes widespread, it is important for plastic surgeons to understand their indications, contraindications, appropriate perioperative management, and impact on plastic surgery procedures.

Biology and Clinical Use of Glucagon-Like Peptide-1 Receptor Agonists in Vascular Protection

Glucagon-like peptide-1 receptor agonists (GLP1RA) are incretin agents initially designed for the treatment of type 2 diabetes mellitus but because of pleiotropic actions are now used to reduce cardiovascular disease in people with type 2 diabetes mellitus and in some instances as approved treatments for obesity. In this review we highlight the biology and pharmacology of GLP1RA. We review the evidence for clinical benefit on major adverse cardiovascular outcomes in addition to modulation of cardiometabolic risk factors including reductions in weight, blood pressure, improvement in lipid profiles, and effects on kidney function. Guidance is provided on indications and potential adverse effects to consider. Finally, we describe the evolving landscape of GLP1RA and including novel glucagon-like peptide-1-based dual/polyagonist therapies that are being evaluated for weight loss, type 2 diabetes mellitus, and cardiorenal benefit.