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Kanaoka T, Wakui H, Yano Y, Nagasu H, Kanegae H, Nangaku M, Hirakawa Y, Nakagawa N, Wada J, Tsuruya K, Nakano T, Maruyama S, Wada T, Konishi M, Nagahiro T, Yamagata K, Narita I, Yanagita M, Terada Y, Araki S, Emoto M, Okada H, Isaka Y, Suzuki Y, Yokoo T, Kataoka H, Kanda E, Kashihara N, Tamura K. Factors affecting the sodium-glucose cotransporter 2 inhibitors-related initial decline in glomerular filtration rate and its possible effect on kidney outcome in chronic kidney disease with type 2 diabetes: The Japan Chronic Kidney Disease Database. Diabetes Obes Metab 2024; 26:2905-2914. [PMID: 38719436 DOI: 10.1111/dom.15611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 06/05/2024]
Abstract
AIM Sodium-glucose cotransporter 2 (SGLT2) inhibitors often cause a transient decrease in glomerular filtration rate (GFR) shortly after the initiation, referred to as the 'initial drop'. However, the clinical significance of this initial drop in real-world practice remains unclear. MATERIALS AND METHODS Using the nationwide Japan Chronic Kidney Disease Database, we examined factors that affected the initial drop, in patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM). We also evaluated the effects of the initial drop on a composite kidney outcome (a decline in GFR of ≥50% or progression to end-stage kidney disease). RESULTS Data from 2053 patients with CKD and T2DM newly prescribed an SGLT2 inhibitor were analysed. The follow-up period after SGLT2 inhibitor administration was 1015 days (interquartile range: 532, 1678). Multivariate linear regression models revealed that the concomitant use of the renin-angiotensin system inhibitors and diuretics, urinary protein levels ≥2+, and changes in GFR before the initiation of the SGLT2 inhibitor were associated with a larger initial GFR decline (β = -0.609, p = .039; β = -2.298, p < .001; β = -0.936, p = .048; β = -0.079, p < .001, respectively). Patients in the quartile with the largest initial GFR decline experienced a higher incidence of the subsequent composite kidney outcome than those in the other quartiles (p < .001). CONCLUSIONS The concomitant use of renin-angiotensin system inhibitors and diuretics, higher urine protein levels and pre-treatment GFR changes were associated with a larger initial GFR decline. Of these factors, the use of a diuretic had the largest effect. Furthermore, patients with CKD and T2DM experiencing an excessive initial GFR drop might be at a higher risk of adverse kidney outcomes.
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Affiliation(s)
- Tomohiko Kanaoka
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiromichi Wakui
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuichiro Yano
- Non-communicable Disease Epidemiology Research Centre, Shiga University of Medical Science, Otsu, Japan
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | | | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yosuke Hirakawa
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Wada
- Department of Nephrology and Rheumatology, Kanazawa University, Kanazawa, Japan
| | - Masaaki Konishi
- Department of Cardiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takanori Nagahiro
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Shinichi Araki
- Department of Nephrology, Wakayama Medical School, Wakayama, Japan
| | - Masanori Emoto
- Metabolism, Endocrinology, and Molecular Medicine, Nephrology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Hiromi Kataoka
- Faculty of Health Science and Technology, Kawasaki University of Medical Welfare, Okayama, Japan
| | - Eiichiro Kanda
- Department of Medical Science, Kawasaki Medical School, Kurashiki, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Bonnet F, Cooper ME, Kopp L, Fouque D, Candido R. A review of the latest real-world evidence studies in diabetic kidney disease: What have we learned about clinical practice and the clinical effectiveness of interventions? Diabetes Obes Metab 2024. [PMID: 38899425 DOI: 10.1111/dom.15710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/20/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
Diabetic nephropathy, also known as diabetic kidney disease (DKD), remains a challenge in clinical practice as this is the major cause of kidney failure worldwide. Clinical trials do not answer all the questions raised in clinical practice and real-world evidence provides complementary insights from randomized controlled trials. Real-life longitudinal data highlight the need for improved screening and management of diabetic nephropathy in primary care. Adherence to the recommended guidelines for comprehensive care appears to be suboptimal in clinical practice in patients with DKD. Barriers to the initiation of sodium-glucose cotransporter-2 (SGLT2) inhibitors for patients with DKD persist in clinical practice, in particular for the elderly. Attainment of blood pressure targets often remains an issue. Initiation of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in routine clinical practice is associated with a reduced risk of albuminuria progression and a possible beneficial effect on kidney function. Real-world evidence confirms a beneficial effect of SGLT2 inhibitors on the decline of glomerular filtration, even in the absence of albuminuria, with a lower risk of acute kidney injury events compared to GLP-1RA use. In addition, SGLT2 inhibitors confer a lower risk of hyperkalaemia after initiation compared with dipeptidyl peptidase-4 inhibitors in patients with DKD. Data from a large population indicate that diuretic treatment increases the risk of a significant decline in glomerular filtration rate in the first few weeks of treatment after SGLT2 inhibitor initiation. The perspective for a global approach targeting multifaceted criteria for diabetic individuals with DKD is emerging based on real-world evidence but there is still a long way to go to achieve this goal.
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Affiliation(s)
- Fabrice Bonnet
- Department of Diabetology, CHU de Rennes, Université de Rennes 1, Rennes, France
| | - Mark E Cooper
- Department of Diabetes, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Laetitia Kopp
- CarMeN Laboratory, INSERM, INRAE, Claude Bernard Lyon 1 University, Pierre Bénite, France
- Department of Nephrology and Nutrition, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Denis Fouque
- CarMeN Laboratory, INSERM, INRAE, Claude Bernard Lyon 1 University, Pierre Bénite, France
- Department of Nephrology and Nutrition, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Riccardo Candido
- Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
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Nyström T. Key results from observational studies and real-world evidence of sodium-glucose cotransporter-2 inhibitor effectiveness and safety in reducing cardio-renal risk. Diabetes Obes Metab 2024. [PMID: 38859661 DOI: 10.1111/dom.15696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/12/2024]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors, originally designed to manage blood sugar levels in individuals with type 2 diabetes (T2D), have emerged as a crucial class of drugs for managing cardio-renal diseases. These drugs work by targeting the SGLT2 protein in the kidneys, promoting the excretion of glucose and influencing metabolic pathways beyond glucose control. The relationship between cardio-renal diseases and SGLT2 inhibitors has been explored through landmark trials and real-world evidence (RWE) studies, demonstrating significant reductions in cardio-renal complications. This review discusses the importance of RWE studies alongside randomized controlled trials in understanding the real-world effectiveness and safety of SGLT2 inhibitors. It outlines the advantages and disadvantages of RWE compared to RCTs, highlighting their complementary roles in providing comprehensive insights into treatment outcomes. By examining a range of RWE studies, the review underscores the cardio-renal benefits of SGLT2 inhibitors across various patient populations. Safety assessments indicate that SGLT2 inhibitors are generally well tolerated, with severe adverse events being rare. Common issues, such as genital mycotic infections and urinary tract infections, are acknowledged, alongside less frequent but significant adverse events including diabetic ketoacidosis, lower-limb amputations, and bone fractures. In summary, SGLT2 inhibitors show promising cardio-renal protective effects in real-world scenarios across diverse populations in T2D, indicating their potential as early intervention measures. Continued research is essential for gaining a thorough understanding of their long-term effects and safety profiles.
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Affiliation(s)
- Thomas Nyström
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Department of Internal Medicine, Section of Endocrinology and Diabetology, Södersjukhuset, Stockholm, Sweden
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Albalawy WN, Youm EB, Shipman KE, Trull KJ, Baty CJ, Long KR, Rbaibi Y, Wang XP, Fagunloye OG, White KA, Jurczak MJ, Kashlan OB, Weisz OA. SGLT2-independent effects of canagliflozin on NHE3 and mitochondrial complex I activity inhibit proximal tubule fluid transport and albumin uptake. Am J Physiol Renal Physiol 2024; 326:F1041-F1053. [PMID: 38660713 DOI: 10.1152/ajprenal.00005.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/03/2024] [Accepted: 04/18/2024] [Indexed: 04/26/2024] Open
Abstract
Beyond glycemic control, SGLT2 inhibitors (SGLT2is) have protective effects on cardiorenal function. Renoprotection has been suggested to involve inhibition of NHE3 leading to reduced ATP-dependent tubular workload and mitochondrial oxygen consumption. NHE3 activity is also important for regulation of endosomal pH, but the effects of SGLT2i on endocytosis are unknown. We used a highly differentiated cell culture model of proximal tubule (PT) cells to determine the direct effects of SGLT2i on Na+-dependent fluid transport and endocytic uptake in this nephron segment. Strikingly, canagliflozin but not empagliflozin reduced fluid transport across cell monolayers and dramatically inhibited endocytic uptake of albumin. These effects were independent of glucose and occurred at clinically relevant concentrations of drug. Canagliflozin acutely inhibited surface NHE3 activity, consistent with a direct effect, but did not affect endosomal pH or NHE3 phosphorylation. In addition, canagliflozin rapidly and selectively inhibited mitochondrial complex I activity. Inhibition of mitochondrial complex I by metformin recapitulated the effects of canagliflozin on endocytosis and fluid transport, whereas modulation of downstream effectors AMPK and mTOR did not. Mice given a single dose of canagliflozin excreted twice as much urine over 24 h compared with empagliflozin-treated mice despite similar water intake. We conclude that canagliflozin selectively suppresses Na+-dependent fluid transport and albumin uptake in PT cells via direct inhibition of NHE3 and of mitochondrial function upstream of the AMPK/mTOR axis. These additional targets of canagliflozin contribute significantly to reduced PT Na+-dependent fluid transport in vivo.NEW & NOTEWORTHY Reduced NHE3-mediated Na+ transport has been suggested to underlie the cardiorenal protection provided by SGLT2 inhibitors. We found that canagliflozin, but not empagliflozin, reduced NHE3-dependent fluid transport and endocytic uptake in cultured proximal tubule cells. These effects were independent of SGLT2 activity and resulted from inhibition of mitochondrial complex I and NHE3. Studies in mice are consistent with greater effects of canagliflozin versus empagliflozin on fluid transport. Our data suggest that these selective effects of canagliflozin contribute to reduced Na+-dependent transport in proximal tubule cells.
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Affiliation(s)
- Wafaa N Albalawy
- Department of Human Genetics, Pitt Public Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Elynna B Youm
- Department of Human Genetics, Pitt Public Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Katherine E Shipman
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Keelan J Trull
- Department of Chemistry and Biochemistry, University of Notre Dame, South Bend, Indiana, United States
| | - Catherine J Baty
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Kimberly R Long
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Youssef Rbaibi
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Xue-Ping Wang
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Olayemi G Fagunloye
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Katharine A White
- Department of Chemistry and Biochemistry, University of Notre Dame, South Bend, Indiana, United States
| | - Michael J Jurczak
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Ossama B Kashlan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Ora A Weisz
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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Kitaoka K, Yano Y, Nagasu H, Kanegae H, Chishima N, Akiyama H, Tamura K, Kashihara N. Kidney outcomes of SGLT2 inhibitors among older patients with diabetic kidney disease in real-world clinical practice: the Japan Chronic Kidney Disease Database Ex. BMJ Open Diabetes Res Care 2024; 12:e004115. [PMID: 38816204 PMCID: PMC11141184 DOI: 10.1136/bmjdrc-2024-004115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 05/16/2024] [Indexed: 06/01/2024] Open
Abstract
INTRODUCTION We compared the kidney outcomes between patients with diabetic kidney disease (DKD) aged ≥75 years initiating sodium-glucose cotransporter 2 (SGLT2) inhibitors versus other glucose-lowering drugs, additionally presenting with or without proteinuria. RESEARCH DESIGN AND METHODS Using the Japan Chronic Kidney Disease Database, we developed propensity scores, implementing a 1:1 matching protocol. The primary outcome included the decline rate in estimated glomerular filtration rate (eGFR), and secondary outcomes incorporated a composite of a 40% reduction in eGFR or progression to end-stage kidney disease. RESULTS At baseline, the mean age at initiation of SGLT2 inhibitors (n=348) or other glucose-lowering medications (n=348) was 77.7 years. The mean eGFR was 59.3 mL/min/1.73m2 and proteinuria was 230 (33.0%) patients. Throughout the follow-up period, the mean annual rate of eGFR change was -0.80 mL/min/1.73 m2/year (95% CI -1.05 to -0.54) among SGLT2 inhibitors group and -1.78 mL/min/1.73 m2/year (95% CI -2.08 to -1.49) in other glucose-lowering drugs group (difference in the rate of eGFR decline between the groups was 0.99 mL/min/1.73 m2/year (95% CI 0.5 to 1.38)), favoring SGLT2 inhibitors (p<0.001). Composite renal outcomes were observed 38 in the SGLT2 inhibitors group and 57 in the other glucose-lowering medications group (HR 0.64, 95% CI 0.42 to 0.97). There was no evidence of an interaction between SGLT2 inhibitors initiation and proteinuria. CONCLUSIONS The benefits of SGLT2 inhibitors on renal outcomes are also applicable to older patients with DKD aged≥75 years.
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Affiliation(s)
- Kaori Kitaoka
- Noncommunicable Disease (NCD) Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan
| | - Yuichiro Yano
- Noncommunicable Disease (NCD) Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan
- Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroshi Kanegae
- Office of Research and Analysis, Genki Plaza Medical Center for Health Care, Tokyo, Japan
| | - Noriharu Chishima
- Cardiovascular, Renal and Metabolism, BioPharmaceuticals Medical, AstraZeneca, Osaka, Japan
| | - Hiroki Akiyama
- Cardiovascular, Renal and Metabolism, BioPharmaceuticals Medical, AstraZeneca, Osaka, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Japan
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Seidu S, Alabraba V, Davies S, Newland-Jones P, Fernando K, Bain SC, Diggle J, Evans M, James J, Kanumilli N, Milne N, Viljoen A, Wheeler DC, Wilding JPH. SGLT2 Inhibitors - The New Standard of Care for Cardiovascular, Renal and Metabolic Protection in Type 2 Diabetes: A Narrative Review. Diabetes Ther 2024; 15:1099-1124. [PMID: 38578397 PMCID: PMC11043288 DOI: 10.1007/s13300-024-01550-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/06/2024] [Indexed: 04/06/2024] Open
Abstract
A substantial evidence base supports the use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in the treatment of type 2 diabetes mellitus (T2DM). This class of medicines has demonstrated important benefits that extend beyond glucose-lowering efficacy to protective mechanisms capable of slowing or preventing the onset of long-term cardiovascular, renal and metabolic (CVRM) complications, making their use highly applicable for organ protection and the maintenance of long-term health outcomes. SGLT2is have shown cost-effectiveness in T2DM management and economic savings over other glucose-lowering therapies due to reduced incidence of cardiovascular and renal events. National and international guidelines advocate SGLT2i use early in the T2DM management pathway, based upon a plethora of supporting data from large-scale cardiovascular outcome trials, renal outcomes trials and real-world studies. While most people with T2DM would benefit from CVRM protection through SGLT2i use, prescribing hesitancy remains, potentially due to confusion concerning their place in the complex therapeutic paradigm, variation in licensed indications or safety perceptions/misunderstandings associated with historical data that have since been superseded by robust clinical evidence and long-term pharmacovigilance reporting. This latest narrative review developed by the Improving Diabetes Steering Committee (IDSC) outlines the place of SGLT2is within current evidence-informed guidelines, examines their potential as the standard of care for the majority of newly diagnosed people with T2DM and sets into context the perceived risks and proven advantages of SGLT2is in terms of sustained health outcomes. The authors discuss the cost-effectiveness case for SGLT2is and provide user-friendly tools to support healthcare professionals in the correct application of these medicines in T2DM management. The previously published IDSC SGLT2i Prescribing Tool for T2DM Management has undergone updates and reformatting and is now available as a Decision Tool in an interactive pdf format as well as an abbreviated printable A4 poster/wall chart.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK
| | - Vicki Alabraba
- Leicester Diabetes Centre, University Hospitals Leicester NHS Trust, Leicester, UK
| | | | | | | | - Stephen C Bain
- Diabetes Research Group, Swansea University Medical School, Swansea University, Swansea, UK
- Department of Diabetes and Endocrinology, Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Jane Diggle
- College Lane Surgery, Ackworth, West Yorkshire, UK
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
| | - June James
- Leicester Diabetes Centre, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Naresh Kanumilli
- Brooklands Northenden Primary Care Network, Manchester, UK
- Manchester University Foundation Trust, Manchester, UK
| | - Nicola Milne
- Brooklands Northenden Primary Care Network, Manchester, UK
| | - Adie Viljoen
- Borthwick Diabetes Research Unit, Lister Hospital, Stevenage, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, Aintree University Hospital, University of Liverpool, Liverpool, UK.
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Iijima H, Gouda M, Hida H, Mori-Anai K, Takahashi A, Minai R, Ninomiya H, Saito Y, Miyawaki A, Wada J. Renal outcomes with sodium-glucose cotransporter 2 inhibitors in Japanese people with grade 3 chronic kidney disease and type 2 diabetes: Analysis of medical administrative databases. Diabetes Obes Metab 2024; 26:1615-1623. [PMID: 38413384 DOI: 10.1111/dom.15461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/25/2023] [Accepted: 01/04/2024] [Indexed: 02/29/2024]
Abstract
AIM To evaluate whether sodium-glucose cotransporter 2 inhibitor (SGLT2i) therapy is associated with a reduction of renal events compared with other glucose-lowering drugs (oGLDs) among Japanese people with type 2 diabetes (T2D) and grade 3 (G3) chronic kidney disease (CKD) in a real-world clinical practice setting. MATERIALS AND METHODS People with T2D who were newly prescribed an SGLT2i or an oGLD from April 2014 to November 2021 (without prior use of index drugs for ≥ 1 year prior to index date) and G3 CKD (estimated glomerular filtration rate [eGFR] ≥ 30 to < 60 mL/min/1.73 m2) were selected from the Medical Data Vision database (MDV-DB) and the Real-World Data database (RWD-DB). SGLT2i and oGLD users were matched (1:1) using propensity score on patient background characteristics. The primary endpoint was a composite of the development of end-stage kidney disease or a sustained decline in eGFR of 50% or more. Hazard ratios (HRs) were estimated using the Cox proportional hazards model. RESULTS Overall, 3190 (1595 per group) patients in the MDV-DB and 2572 (1286 per group) patients in the RWD-DB were included in the analyses. The composite outcome was significantly lower in the SGLT2i group than in the oGLD group in the MDV-DB (HR 0.49, 95% confidence interval [CI] 0.33 to 0.74, P < 0.001) and in the RWD-DB (HR 0.57, 95% CI 0.37 to 0.88, P = 0.011). CONCLUSIONS Japanese people with T2D and G3 CKD initiating an SGLT2i had a lower risk of renal events than people initiating an oGLD.
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Affiliation(s)
- Hiroaki Iijima
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Maki Gouda
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Hideaki Hida
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Kazumi Mori-Anai
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Akiko Takahashi
- Ikuyaku. Integrated Value Development Division, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | | | | | | | - Atsushi Miyawaki
- Datack, Inc., Tokyo, Japan
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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8
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de Germay S, Pambrun E, Pariente A, Grenet G, Bezin J, Faillie JL. Use of sodium-glucose cotransporter-2 inhibitors in France: Analysis of French nationwide health insurance database. Diabetes Obes Metab 2024; 26:1678-1686. [PMID: 38288619 DOI: 10.1111/dom.15472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/04/2024] [Accepted: 01/12/2024] [Indexed: 04/09/2024]
Abstract
AIM Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) have been commercialized in France for type 2 diabetes since April 2020 and later for heart and renal diseases. Given the recent developments in treating diabetes and the widening of SGLT-2i indications, we aimed to study changes in the use of glucose-lowering drugs in France and to characterize SGLT-2i new users. METHODS We performed a nationwide utilization study using the French health insurance database. Trends in incidence and prevalence of glucose-lowering drug use were assessed by a repeated cross-sectional study in 2019 and 2021. A cohort study of incident SGLT-2i users was then conducted to describe patient characteristics and the strategy for treating diabetes. RESULTS The prevalence of SGLT-2i use gradually reached 0.1% in the third quarter of 2021 and increased more significantly to 0.2% thereafter. SGLT-2i became the second most prescribed glucose-lowering drug class after metformin at the end of 2021 (0.1%). Among the cohort of 125 387 SGLT-2i new users (mean age 65.0 years; 60.1% of men), 87.6% presented a diabetic comorbidity. The patient profile changed over the study period with an increasing proportion of patients with cardiovascular (28.7% in 2020 vs. 40.2% in 2021) or renal (7.7% in 2020 vs. 11.8% in 2021) comorbidities at initiation. The main combinations used at SGLT-2i initiation were metformin (12.5%) and metformin plus dipeptidyl peptidase-4 inhibitors (8.1%). One-year probability of SGLT-2i persistence was estimated to be 55%. CONCLUSION The expansion of indications for SGLT-2i and the broadening of the target population make it essential to assess the reasons for discontinuation and review their safety profile.
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Affiliation(s)
- Sibylle de Germay
- Univ. Bordeaux, INSERM, BPH, U1219 Team AHeaD, Bordeaux, France
- Department of Medical Pharmacology, CHU de Bordeaux, Bordeaux, France
| | - Elodie Pambrun
- Univ. Bordeaux, INSERM, BPH, U1219 Team AHeaD, Bordeaux, France
| | - Antoine Pariente
- Univ. Bordeaux, INSERM, BPH, U1219 Team AHeaD, Bordeaux, France
- Department of Medical Pharmacology, CHU de Bordeaux, Bordeaux, France
| | - Guillaume Grenet
- Department of Medical Pharmacotoxicology, Hospices Civils de Lyon, Lyon, France
| | - Julien Bezin
- Univ. Bordeaux, INSERM, BPH, U1219 Team AHeaD, Bordeaux, France
- Department of Medical Pharmacology, CHU de Bordeaux, Bordeaux, France
| | - Jean-Luc Faillie
- Department of Medical Pharmacology and Toxicology, CHU Montpellier; Univ Montpellier, IDESP INSERM, Montpellier, France
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9
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Preda A, Montecucco F, Carbone F, Camici GG, Lüscher TF, Kraler S, Liberale L. SGLT2 inhibitors: from glucose-lowering to cardiovascular benefits. Cardiovasc Res 2024; 120:443-460. [PMID: 38456601 DOI: 10.1093/cvr/cvae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
An increasing number of individuals are at high risk of type 2 diabetes (T2D) and its cardiovascular complications, including heart failure (HF), chronic kidney disease (CKD), and eventually premature death. The sodium-glucose co-transporter-2 (SGLT2) protein sits in the proximal tubule of human nephrons to regulate glucose reabsorption and its inhibition by gliflozins represents the cornerstone of contemporary T2D and HF management. Herein, we aim to provide an updated overview of the pleiotropy of gliflozins, provide mechanistic insights and delineate related cardiovascular (CV) benefits. By discussing contemporary evidence obtained in preclinical models and landmark randomized controlled trials, we move from bench to bedside across the broad spectrum of cardio- and cerebrovascular diseases. With landmark randomized controlled trials confirming a reduction in major adverse CV events (MACE; composite endpoint of CV death, non-fatal myocardial infarction, and non-fatal stroke), SGLT2 inhibitors strongly mitigate the risk for heart failure hospitalization in diabetics and non-diabetics alike while conferring renoprotection in specific patient populations. Along four major pathophysiological axes (i.e. at systemic, vascular, cardiac, and renal levels), we provide insights into the key mechanisms that may underlie their beneficial effects, including gliflozins' role in the modulation of inflammation, oxidative stress, cellular energy metabolism, and housekeeping mechanisms. We also discuss how this drug class controls hyperglycaemia, ketogenesis, natriuresis, and hyperuricaemia, collectively contributing to their pleiotropic effects. Finally, evolving data in the setting of cerebrovascular diseases and arrhythmias are presented and potential implications for future research and clinical practice are comprehensively reviewed.
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Affiliation(s)
- Alberto Preda
- Department of Clinical Cardiology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Royal Brompton and Harefield Hospitals and Imperial College and King's College, London, United Kingdom
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
- Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
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10
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Yoshida N, Hanai K, Babazono T. Comparative effects of sodium-glucose cotransporter 2 inhibitors versus dipeptidyl peptidase-4 inhibitors on kidney function decline in Japanese individuals with type 2 diabetes. Clin Exp Nephrol 2024:10.1007/s10157-024-02499-2. [PMID: 38613740 DOI: 10.1007/s10157-024-02499-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/27/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Limited direct comparative studies exist in terms of the effects of sodium-glucose cotransporter 2 inhibitors (SGLT2is) and dipeptidyl peptidase-4 inhibitors (DPP4is) on the kidney outcomes in Japanese individuals with type 2 diabetes. METHODS This retrospective cohort study included 561 Japanese adults with type 2 diabetes, who were newly prescribed either an SGLT2i or a DPP4i and had an eGFR ≥ 30 mL/min/1.73 m2. The cohort comprised 207 women and 354 men, with a mean (± standard deviation) age of 63 (± 12) years. The exposure and outcome were SGLT2i or DPP4i initiation and eGFR slope during the overall follow-up period, restricted to participants who were followed for ≥2 years. We adopted the on-treatment analysis. Analysis of covariance was used to compare the adjusted eGFR slope between the two groups, incorporating 10 variables at baseline. RESULTS During the median follow-up period of 3.4 years, least square mean (95% CI) eGFR slopes were -1.91 (-2.15, -1.67) and -1.12 (-1.58, -0.67) mL/min/1.73 m2/year in individuals treated with a DPP4i (n = 460) and an SGLT2i (n = 101), respectively, demonstrating statistical significance (p = 0.002). The robustness of this finding was strengthened by sensitivity analyses. CONCLUSIONS This study provides potential evidence of the superiority of SGLT2is over DPP4is in slowing kidney function decline in Japanese adults with type 2 diabetes and eGFR ≥ 30 mL/min/1.73 m2.
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Affiliation(s)
- Naoshi Yoshida
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Ko Hanai
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan.
| | - Tetsuya Babazono
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
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11
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Khater J, Malakouti S, Khoury AE, Cortese B. Performance of sodium-glucose cotransporter 2 inhibitors in cardiovascular disease. J Cardiovasc Med (Hagerstown) 2024; 25:247-258. [PMID: 38305141 DOI: 10.2459/jcm.0000000000001598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
AIMS The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) as a new class of drug in treating type 2 diabetes has expanded beyond its original framework. Positive results have been achieved in reducing symptoms in patients with cardiovascular disease (CVD). The aim of this article is to present an in-depth review of the basic principles of this class of medications and how it has brought benefits to patients affected particularly by heart failure. METHODS Following a thorough PubMed search, this review includes 62 studies published between 2015 and 2023. Keywords searched included 'sodium-glucose cotransporter 2 inhibitors', 'cardiovascular disease', 'heart failure', 'chronic kidney disease', and 'type 2 diabetes'. The most recent and comprehensive data were used. RESULTS Positive results have been achieved in reducing symptoms in patients with CVD. SGLT2 inhibitors have also been shown to be useful in other contexts such as nonalcoholic fatty liver disease (NAFLD) by reducing liver fat accumulation, kidney benefits by improving body weight and vascular endothelium, improving eGFR, and reducing progression to end stage kidney disease (ESKD). SGLT2 inhibitors are also effective in reducing the need for heart failure hospitalizations and the risk of serious cardiac adverse events, including cardiovascular and all-cause mortality, in patients with reduced or preserved left ventricular (LV) ejection fraction and in acute or decompensated settings. CONCLUSION SGLT2 inhibitors have evolved into metabolic drugs because of their multisystem action and are indicated for the treatment of all spectrums of heart failure, type 2 diabetes, and chronic kidney disease.
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Affiliation(s)
- Jacinthe Khater
- DCB Academy, Milan, Italy
- Faculty of Medical Sciences, Lebanese University Rafic Hariri University Campus Hadath
| | | | - Antoine El Khoury
- DCB Academy, Milan, Italy
- Department of Cardiology, Faculty of Medicine and Medical Sciences, University of Balamand, Beirut, Lebanon
| | - Bernardo Cortese
- DCB Academy, Milan, Italy
- Fondazione Ricerca e Innovazione Cardiovascolare, Milan, Italy
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12
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Spasovski G, Rroji M, Hristov G, Bushljetikj O, Spahia N, Rambabova Bushletikj I. A New Hope on the Horizon for Kidney and Cardiovascular Protection with SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Mineralocorticoid Receptor Antagonists in Type 2 Diabetic and Chronic Kidney Disease Patients. Metab Syndr Relat Disord 2024; 22:170-178. [PMID: 38386800 DOI: 10.1089/met.2023.0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Type 2 diabetes (T2D) is the leading cause of chronic kidney disease (CKD). In addition, the cardiovascular prevalence in diabetic patients is around 32.2%, with a two-fold increased mortality risk compared to those without diabetes. Recent investigations have shed light on the promising cardioprotective and nephroprotective benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1RA), and nonsteroidal mineralocorticoid receptor antagonists (nsMRAs) for individuals with T2D. The evidence robustly indicates that SGLT2i and GLP-1RA significantly reduce the risk of CKD and cardiovascular disease (CVD), all while effectively managing blood glucose levels. Furthermore, combining SGLT2i with nsMRAs amplifies the benefits, potentially offering a more profound reduction in cardiovascular and renal outcomes. The data analysis strongly supports the integration of these pharmacological agents in the management strategies for CKD and CVD prevention among T2D patients, highlighting the importance of awareness among nephrologists, especially in regions with limited healthcare resources.
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Affiliation(s)
- Goce Spasovski
- Department of Nephrology, Medical Faculty, University Sts. Cyril and Methodius, Skopje, North Macedonia
| | - Merita Rroji
- Department of Nephrology, University of Medicine of Tirana, Tirana, Albania
| | - Goce Hristov
- Department of Internal Medicine and Diabetes, General Public Hospital Strumica, Strumica, North Macedonia
| | - Oliver Bushljetikj
- Department of Cardiology, Medical Faculty, University Sts. Cyril and Methodius, Skopje, North Macedonia
| | - Nereida Spahia
- Department of Nephrology, University of Medicine of Tirana, Tirana, Albania
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13
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Islam L, Jose D, Alkhalifah M, Blaibel D, Chandrabalan V, Pappachan JM. Comparative efficacy of sodium glucose cotransporter-2 inhibitors in the management of type 2 diabetes mellitus: A real-world experience. World J Diabetes 2024; 15:463-474. [PMID: 38591092 PMCID: PMC10999032 DOI: 10.4239/wjd.v15.i3.463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/02/2024] [Accepted: 02/18/2024] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Sodium glucose cotransporter-2 inhibitors (SGLT-2i) are a class of drugs with modest antidiabetic efficacy, weight loss effect, and cardiovascular benefits as proven by multiple randomised controlled trials (RCTs). However, real-world data on the comparative efficacy and safety of individual SGLT-2i medications is sparse. AIM To study the comparative efficacy and safety of SGLT-2i using real-world clinical data. METHODS We evaluated the comparative efficacy data of 3 SGLT-2i drugs (dapagliflozin, canagliflozin, and empagliflozin) used for treating patients with type 2 diabetes mellitus. Data on the reduction of glycated hemoglobin (HbA1c), body weight, blood pressure (BP), urine albumin creatinine ratio (ACR), and adverse effects were recorded retrospectively. RESULTS Data from 467 patients with a median age of 64 (14.8) years, 294 (62.96%) males and 375 (80.5%) Caucasians were analysed. Median diabetes duration was 16.0 (9.0) years, and the duration of SGLT-2i use was 3.6 (2.1) years. SGLT-2i molecules used were dapagliflozin 10 mg (n = 227; 48.6%), canagliflozin 300 mg (n = 160; 34.3%), and empagliflozin 25 mg (n = 80; 17.1). Baseline median (interquartile range) HbA1c in mmol/mol were: dapagliflozin - 78.0 (25.3), canagliflozin - 80.0 (25.5), and empagliflozin - 75.0 (23.5) respectively. The respective median HbA1c reduction at 12 months and the latest review (just prior to the study) were: 66.5 (22.8) & 69.0 (24.0), 67.0 (16.3) & 66.0 (28.0), and 67.0 (22.5) & 66.5 (25.8) respectively (P < 0.001 for all comparisons from baseline). Significant improvements in body weight (in kilograms) from baseline to study end were noticed with dapagliflozin - 101 (29.5) to 92.2 (25.6), and canagliflozin 100 (28.3) to 95.3 (27.5) only. Significant reductions in median systolic and diastolic BP, from 144 (21) mmHg to 139 (23) mmHg; (P = 0.015), and from 82 (16) mmHg to 78 (19) mmHg; (P < 0.001) respectively were also observed. A significant reduction of microalbuminuria was observed with canagliflozin only [ACR 14.6 (42.6) at baseline to 8.9 (23.7) at the study end; P = 0.043]. Adverse effects of SGLT-2i were as follows: genital thrush and urinary infection - 20 (8.8%) & 17 (7.5%) with dapagliflozin; 9 (5.6%) & 5 (3.13%) with canagliflozin; and 4 (5%) & 4 (5%) with empagliflozin. Diabetic ketoacidosis was observed in 4 (1.8%) with dapagliflozin and 1 (0.63%) with canagliflozin. CONCLUSION Treatment of patients with SGLT-2i is associated with statistically significant reductions in HbA1c, body weight, and better than those reported in RCTs, with low side effect profiles. A review of large-scale real-world data is needed to inform better clinical practice decision making.
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Affiliation(s)
- Lubna Islam
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
| | - Dhanya Jose
- Department of Community Medicine, Goa Medical College, Goa 403202, India
| | - Mohammed Alkhalifah
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
- Department of Family Medicine, King Faisal Specialist Hospital, Riyadh 11564, Saudi Arabia
| | - Dania Blaibel
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
| | - Vishnu Chandrabalan
- Department of Data Science, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
| | - Joseph M Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
- Faculty of Science, Manchester Metropolitan University, All Saints Building, Manchester M15 6BH, United Kingdom
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, United Kingdom
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14
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Yang CT, Yao WY, Yang CY, Peng ZY, Ou HT, Kuo S. Lower risks of cirrhosis and hepatocellular carcinoma with GLP-1RAs in type 2 diabetes: A nationwide cohort study using target trial emulation framework. J Intern Med 2024; 295:357-368. [PMID: 37994187 DOI: 10.1111/joim.13751] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND To assess the association of cirrhosis and hepatocellular carcinoma (HCC) with the use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) versus long-acting insulins (LAIs), which are the two commonly prescribed injectable glucose-lowering agents (GLAs) for patients with type 2 diabetes (T2D) after the failure of multiple oral GLAs. METHODS We emulated a target trial using the nationwide data of a Taiwanese cohort with T2D. Incident new users of GLP-1RAs and LAIs during 2013-2018 were identified, and propensity score (PS) matching was applied to ensure between-group comparability in baseline patient characteristics. The primary outcome was the composite liver disease including cirrhosis or HCC. Each patient was followed until the occurrence of a study outcome, death, or the end of 2019, whichever came first. Subdistribution hazard models were employed to assess the treatment-outcome association. Sensitivity (e.g., stabilized inverse probability of treatment weighting analysis, time-dependent analysis), E-value, and negative control outcome analyses were performed to examine the robustness of study findings. RESULTS We included 7171 PS-matched pairs of GLP-1RA and LAI users with no significant between-group differences at baseline. Compared with LAIs, the use of GLP-1RAs was associated with significantly reduced risks of composite liver disease (subdistribution hazard ratio [95% confidence interval]: 0.56 [0.42-0.76]), cirrhosis (0.59 [0.43-0.81]), and HCC (0.47 [0.24-0.93]). Results were consistent across sensitivity analyses and among patients with different baseline characteristics. CONCLUSION Among T2D patients who require injectable GLAs, the use of GLP-1RAs versus LAIs was associated with lower risks of cirrhosis and HCC.
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Affiliation(s)
- Chun-Ting Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, USA
| | - Wen-Yu Yao
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chen-Yi Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Zi-Yang Peng
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shihchen Kuo
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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15
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Fadini GP, Longato E, Morieri ML, Del Prato S, Avogaro A, Solini A. Long-term benefits of dapagliflozin on renal outcomes of type 2 diabetes under routine care: a comparative effectiveness study on propensity score matched cohorts at low renal risk. THE LANCET REGIONAL HEALTH. EUROPE 2024; 38:100847. [PMID: 38328413 PMCID: PMC10847023 DOI: 10.1016/j.lanepe.2024.100847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 12/29/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024]
Abstract
Background Despite the overall improvement in care, people with type 2 diabetes (T2D) experience an excess risk of end-stage kidney disease. We evaluated the long-term effectiveness of dapagliflozin on kidney function and albuminuria in patients with T2D. Methods We included patients with T2D who initiated dapagliflozin or comparators from 2015 to 2020. Propensity score matching (PSM) was performed to balance the two groups. The primary endpoint was the change in estimated glomerular filtration rate (eGFR) from baseline to the end of observation. Secondary endpoints included changes in albuminuria and loss of kidney function. Findings We analysed two matched groups of 6197 patients each. The comparator group included DPP-4 inhibitors (40%), GLP-1RA (22.3%), sulphonylureas (16.1%), pioglitazone (8%), metformin (5.8%), or acarbose (4%). Only 6.4% had baseline eGFR <60 ml/min/1.73 m2 and 15% had UACR >30 mg/g. During a mean follow-up of 2.5 year, eGFR declined significantly less in the dapagliflozin vs comparator group by 1.81 ml/min/1.73 m2 (95% C.I. from 1.13 to 2.48; p < 0.0001). The mean eGFR slope was significantly less negative in the dapagliflozin group by 0.67 ml/min/1.73 m2/year (95% C.I. from 0.47 to 0.88; p < 0.0001). Albuminuria declined significantly in new-users of dapagliflozin within 6 months and remained on average 44.3 mg/g lower (95% C.I. from -66.9 to -21.7; p < 0.0001) than in new-users of comparators. New-users of dapagliflozin had significantly lower rates of new-onset CKD, loss of kidney function, and a composite renal outcome. Results were confirmed for all SGLT2 inhibitors, in patients without baseline CKD, and when GLP-1RA were excluded from comparators. Interpretation Initiating dapagliflozin improved kidney function outcomes and albuminuria in patients with T2D and a low renal risk. Funding Funded by the Italian Diabetes Society and partly supported by a grant from AstraZeneca.
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Affiliation(s)
- Gian Paolo Fadini
- Division of Metabolic Diseases, Department of Medicine, University of Padova, 35128 Padova, Italy
- Laboratory of Experimental Diabetology, Veneto Institute of Molecular Medicine, 35128 Padova, Italy
| | - Enrico Longato
- Department of Information Engineering, University of Padova, 35100 Padua, Italy
| | - Mario Luca Morieri
- Division of Metabolic Diseases, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Stefano Del Prato
- Department of Clinical & Experimental Medicine, University of Pisa and Sant’Anna School of Advanced Studies, 56126 Pisa, Italy
| | - Angelo Avogaro
- Division of Metabolic Diseases, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Italy
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16
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Neumiller JJ, St. Peter WL, Shubrook JH. Type 2 Diabetes and Chronic Kidney Disease: An Opportunity for Pharmacists to Improve Outcomes. J Clin Med 2024; 13:1367. [PMID: 38592214 PMCID: PMC10932148 DOI: 10.3390/jcm13051367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 04/10/2024] Open
Abstract
Chronic kidney disease (CKD) is an important contributor to end-stage kidney disease, cardiovascular disease, and death in people with type 2 diabetes (T2D), but current evidence suggests that diagnosis and treatment are often not optimized. This review examines gaps in care for patients with CKD and how pharmacist interventions can mitigate these gaps. We conducted a PubMed search for published articles reporting on real-world CKD management practice and compared the findings with current recommendations. We find that adherence to guidelines on screening for CKD in patients with T2D is poor with particularly low rates of testing for albuminuria. When CKD is diagnosed, the prescription of recommended heart-kidney protective therapies is underutilized, possibly due to issues around treatment complexity and safety concerns. Cost and access are barriers to the prescription of newer therapies and treatment is dependent on racial, ethnic, and socioeconomic factors. Rates of nephrologist referrals for difficult cases are low in part due to limitations of information and communication between specialties. We believe that pharmacists can play a vital role in improving outcomes for patients with CKD and T2D and support the cost-effective use of healthcare resources through the provision of comprehensive medication management as part of a multidisciplinary team. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across healthcare systems to ensure that comprehensive medication management can be optimally implemented.
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Affiliation(s)
- Joshua J. Neumiller
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA 99210, USA
| | - Wendy L. St. Peter
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Jay H. Shubrook
- Department of Clinical Sciences and Community Health, Touro University California, Vallejo, CA 94592, USA;
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17
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Tomita-Yagi A, Ozeki-Okuno N, Watanabe-Uehara N, Komaki K, Umehara M, Sawada-Yamauchi H, Minamida A, Sunahara Y, Matoba Y, Nakamura I, Nakata T, Nakai K, Ida T, Yamashita N, Kamezaki M, Kirita Y, Taniguchi T, Konishi E, Matoba S, Tamagaki K, Kusaba T. The importance of proinflammatory failed-repair tubular epithelia as a predictor of diabetic kidney disease progression. iScience 2024; 27:109020. [PMID: 38357667 PMCID: PMC10865398 DOI: 10.1016/j.isci.2024.109020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/17/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
The immense public health burden of diabetic kidney disease (DKD) has led to an increase in research on the pathophysiology of advanced DKD. The present study focused on the significance of proinflammatory vascular cell adhesion molecule 1 (VCAM1)+ tubules in DKD progression. A retrospective cohort study of DKD patients showed that the percentage of VCAM1+ tubules in kidney samples was correlated with poor renal outcomes. We established an advanced DKD model by partial resection of the kidneys of db/db mice and demonstrated that it closely resembled the human advanced DKD phenotype, with tissue hypoxia, tubular DNA damage, tissue inflammation, and high tubular VCAM1 expression. Luseogliflozin ameliorated tissue hypoxia and proinflammatory responses, including VCAM1+ expression, in tubules. These findings suggest the potential of tubular VCAM1 as a histological marker for poor DKD outcomes. SGLT2 inhibitors may attenuate tissue hypoxia and subsequent tissue inflammation in advanced DKD, thereby ameliorating tubular injury.
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Affiliation(s)
- Aya Tomita-Yagi
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Natsuko Ozeki-Okuno
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Noriko Watanabe-Uehara
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazumi Komaki
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Minato Umehara
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroko Sawada-Yamauchi
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Atsushi Minamida
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuto Sunahara
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yayoi Matoba
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Itaru Nakamura
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomohiro Nakata
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kunihiro Nakai
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomoharu Ida
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Noriyuki Yamashita
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Michitsugu Kamezaki
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuhei Kirita
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takuya Taniguchi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Eiichi Konishi
- Department of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Tamagaki
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuro Kusaba
- Department of Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Tsur AM, Akavian I, Landau R, Derazne E, Tzur D, Vivante A, Grossman E, Rotem RS, Fishman B, Pinhas-Hamiel O, Afek A, Coresh J, Chodick G, Twig G. Adolescent Body Mass Index and Early Chronic Kidney Disease in Young Adulthood. JAMA Pediatr 2024; 178:142-150. [PMID: 38079159 PMCID: PMC10714283 DOI: 10.1001/jamapediatrics.2023.5420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/03/2023] [Indexed: 02/06/2024]
Abstract
Importance Despite increasing obesity rates in adolescents, data regarding early kidney sequelae are lacking. Objective To assess the association between adolescent body mass index (BMI) and early chronic kidney disease (CKD) in young adulthood (<45 years of age). Design, Setting, and Participants This cohort study linked screening data of mandatory medical assessments of Israeli adolescents to data from a CKD registry of a national health care system. Adolescents who were aged 16 to 20 years; born since January 1, 1975; medically evaluated for mandatory military service through December 31, 2019; and insured by Maccabi Healthcare Services were assessed. Individuals with kidney pathology, albuminuria, hypertension, dysglycemia, or missing blood pressure or BMI data were excluded. Body mass index was calculated as weight in kilograms divided by height in meters squared and categorized by age- and sex-matched percentiles according to the US Centers for Disease Control and Prevention. Follow-up started at the time of medical evaluation or January 1, 2000 (whichever came last), and ended at early CKD onset, death, the last day insured, or August 23, 2020 (whichever came first). Data analysis was performed from December 19, 2021, to September 11, 2023. Main Outcomes and Measures Early CKD, defined as stage 1 to 2 CKD by moderately or severely increased albuminuria, with an estimated glomerular filtration rate of 60 mL/min/1.73 m2 or higher. Results Of 629 168 adolescents evaluated, 593 660 (mean [SD] age at study entry, 17.2 [0.5] years; 323 293 [54.5%] male, 270 367 [45.5%] female) were included in the analysis. During a mean (SD) follow-up of 13.4 (5.5) years for males and 13.4 (5.6) years for females, 1963 adolescents (0.3%) developed early CKD. Among males, the adjusted hazard ratios were 1.8 (95% CI, 1.5-2.2) for adolescents with high-normal BMI, 4.0 (95% CI, 3.3-5.0) for those with overweight, 6.7 (95% CI, 5.4-8.4) for those with mild obesity, and 9.4 (95% CI, 6.6-13.5) for those with severe obesity. Among females, the hazard ratios were 1.4 (95% CI, 1.2-1.6) for those with high-normal BMI, 2.3 (95% CI, 1.9-2.8) for those with overweight, 2.7 (95% CI, 2.1-3.6) for those with mild obesity, and 4.3 (95% CI, 2.8-6.5) for those with severe obesity. The results were similar when the cohort was limited to individuals who were seemingly healthy as adolescents, individuals surveyed up to 30 years of age, or those free of diabetes and hypertension at the end of the follow-up. Conclusions and Relevance In this cohort study, high BMI in late adolescence was associated with early CKD in young adulthood. The risk was also present in seemingly healthy individuals with high-normal BMI and before 30 years of age, and a greater risk was seen among those with severe obesity. These findings underscore the importance of mitigating adolescent obesity rates and managing risk factors for kidney disease in adolescents with high BMI.
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Affiliation(s)
- Avishai M. Tsur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
- Department of Medicine, Sheba Medical Center, Tel HaShomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Inbal Akavian
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Regev Landau
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
- Department of Medicine, Sheba Medical Center, Tel HaShomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Estela Derazne
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dorit Tzur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Asaf Vivante
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatrics B and Pediatric Nephrology Unit, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Ehud Grossman
- Department of Medicine, Sheba Medical Center, Tel HaShomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran S. Rotem
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Boris Fishman
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Cardiology, Sheba Medical Center, Tel HaShomer, Israel
| | - Orit Pinhas-Hamiel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Arnon Afek
- Central Management, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gabriel Chodick
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Gilad Twig
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- Department of Military Medicine, Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Department of Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Ramat Gan, Israel
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19
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Pollock C, Sanchez JJG, Carrero JJ, Kumar S, Pecoits-Filho R, Lam CSP, Chen H, Kanda E, Lainscak M, Wheeler DC. Glucose-lowering treatment pathways of individuals with chronic kidney disease and type 2 diabetes according to the Kidney Disease: Improving Global Outcomes 2012 risk classification. Diabet Med 2024; 41:e15200. [PMID: 37578188 DOI: 10.1111/dme.15200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 08/15/2023]
Abstract
AIMS To describe treatment pathways for key glucose-lowering therapies in individuals with chronic kidney disease (CKD) and type 2 diabetes (T2D) using retrospective data from DISCOVER CKD (NCT04034992). METHODS Data were extracted from the UK Clinical Practice Research Datalink (CPRD) linked to Hospital Episode Statistics data (2008-2020) and the US integrated Limited Claims and Electronic Health Records Database (LCED; 2012-2019). Eligible individuals were aged ≥18 years with CKD, identified by two consecutive estimated glomerular filtration rate (eGFR) measures (15-<75 mL/min/1.73 m2 ; 90-730 days apart; index date was the second measurement) and T2D. Chronological treatment pathways for glucose-lowering therapies prescribed on or after CKD index to end of follow-up were computed. Median time and proportion of overall follow-up time on treatment were described for each therapy by database and by eGFR and urinary albumin-to-creatinine ratio (UACR) categories. RESULTS Of 36,951 and 4339 eligible individuals in the CPRD and LCED, respectively, median baseline eGFR was 67.8 and 64.9 mL/min/1.73 m2 ; 64.2 and 63.9% received metformin prior to index; and median (interquartile range) time on metformin during follow-up was 917 (390-1671) and 454 (192-850) days (accounting for ~75% of follow-up time in both databases). The frequency of combination treatment increased over time. There were trends towards decreased metformin prescriptions with decreasing eGFR and increasing UACR within each eGFR category. CONCLUSIONS Individuals with CKD and T2D had many combinations of therapies and substantial follow-up time on therapy. These results highlight opportunities for improved CKD management.
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Affiliation(s)
- Carol Pollock
- Royal North Shore Hospital, Kolling Institute, University of Sydney, St Leonards, New South Wales, Australia
| | | | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Supriya Kumar
- Real World Data Science, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifical Catholic University of Parana, Curitiba, Brazil
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Carolyn S P Lam
- Department of Cardiology, National Heart Centre Singapore, Singapore City, Singapore
- Duke-NUS Medical School, Singapore City, Singapore
| | - Hungta Chen
- Medical and Payer Evidence Statistics, BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
| | | | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
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20
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Elkeraie AF, Al-Ghamdi S, Abu-Alfa AK, Alotaibi T, AlSaedi AJ, AlSuwaida A, Arici M, Ecder T, Ghnaimat M, Hafez MH, Hassan MH, Sqalli T. Impact of Sodium-Glucose Cotransporter-2 Inhibitors in the Management of Chronic Kidney Disease: A Middle East and Africa Perspective. Int J Nephrol Renovasc Dis 2024; 17:1-16. [PMID: 38196830 PMCID: PMC10771977 DOI: 10.2147/ijnrd.s430532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024] Open
Abstract
Chronic kidney disease (CKD) is a major public health concern in the Middle East and Africa (MEA) region and a leading cause of death in patients with type 2 diabetes mellitus (T2DM) and hypertension. Early initiation of sodium-glucose cotransporter - 2 inhibitors (SGLT-2i) and proper sequencing with renin-angiotensin-aldosterone system inhibitors (RAASi) in these patients may result in better clinical outcomes due to their cardioprotective properties and complementary mechanisms of action. In this review, we present guideline-based consensus recommendations by experts from the MEA region, as practical algorithms for screening, early detection, nephrology referral, and treatment pathways for CKD management in patients with hypertension and diabetes mellitus. This study will help physicians take timely and appropriate actions to provide better care to patients with CKD or those at high risk of CKD.
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Affiliation(s)
- Ahmed Fathi Elkeraie
- Department of Internal Medicine and Nephrology, Alexandria University, Alexandria, Egypt
| | - Saeed Al-Ghamdi
- Department of Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ali K Abu-Alfa
- Department of Internal Medicine, Division of Nephrology and Hypertension, American University of Beirut, Beirut, Lebanon
| | - Torki Alotaibi
- Transplant Nephrology, Hamed Al-Essa Organ Transplant Center, Sabah Health Region, Kuwait City, Kuwait
| | - Ali Jasim AlSaedi
- Department of Nephrology, College of Medicine, University of Baghdad, Nephrology and Transplantation Center, Medical City Complex, Baghdad, Iraq
| | | | - Mustafa Arici
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Altındağ, Ankara, Turkey
| | - Tevfik Ecder
- Department of Medicine, Istinye University; Division of Nephrology, Topkapı, Istanbul, Turkey
| | - Mohammad Ghnaimat
- Department of Nephrology, Specialty Hospital, Jaber Ibn Hayyan St. Shmeisani, Amman, Jordan
| | | | - Mohamed H Hassan
- Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Tarik Sqalli
- Department of Nephrology, Moroccan Society of Nephrology, Casablanca, Morocco
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21
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Zhu J, Wilding JPH. Body Fat Depletion: the Yin Paradigm for Treating Type 2 Diabetes. Curr Atheroscler Rep 2024; 26:1-10. [PMID: 38148417 PMCID: PMC10776473 DOI: 10.1007/s11883-023-01181-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE OF REVIEW To highlight that body fat depletion (the Yin paradigm) with glucose-lowering treatments (the Yang paradigm) are associated with metabolic benefits for patients with type 2 diabetes mellitus (T2DM). RECENT FINDINGS The sodium-glucose cotransporter-2 inhibitor-mediated sodium/glucose deprivation can directly improve glycemic control and kidney outcome in patients with T2DM. The glucose deprivation might also promote systemic fatty acid β-oxidation to deplete ectopic/visceral fat and thereby contribute to the prevention of cardiovascular diseases. As with metabolic surgery, bioengineered incretin-based medications with potent anorexigenic and insulinotropic efficacy can significantly reduce blood glucose as well as body weight (especially in the ectopic/visceral fat depots). The latter effects could be a key contributor to their cardiovascular-renal protective effects. In addition to a healthy diet, the newer glucose-lowering medications, with body fat reduction effects, should be prioritized when treating patients with T2DM, especially for those with established cardiovascular/renal risks or diseases.
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Affiliation(s)
- Jingjing Zhu
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Clinical Sciences Centre, Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Clinical Sciences Centre, Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK.
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22
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Tan SK, Pinzon-Cortes JA, Cooper ME. Novel pharmacological interventions for diabetic kidney disease. Curr Opin Nephrol Hypertens 2024; 33:13-25. [PMID: 37889557 DOI: 10.1097/mnh.0000000000000935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the latest evidence on the prevention and progression of diabetic kidney disease (DKD), as well as novel pharmacological interventions from preclinical and early clinical studies with promising findings in the reduction of this condition's burden. RECENT FINDINGS We will cover the latest evidence on the reduction of proteinuria and kidney function decline in DKD achieved through established renin-angiotensin-aldosterone system (RAAS) system blockade and the more recent addition of SGLT2i, nonsteroidal mineralocorticoid receptor antagonists (MRAs) and GLP1-RA, that combined will most likely integrate the mainstay for current DKD treatment. We also highlight evidence from new mechanisms of action in DKD, including other haemodynamic anti-inflammatory and antifibrotic interventions, oxidative stress modulators and cell identity and epigenetic targets. SUMMARY Renal specific outcome trials have become more popular and are increasing the available armamentarium to diminish the progression of renal decline in patients at greater risk of end-stage kidney disease (ESKD) such as diabetic individuals. A combined pharmaceutical approach based on available rigorous studies should include RAAS blockade, SGLT2 inhibitors, nonsteroidal MRA and expectedly GLP1-RA on a personalized based-intervention. New specific trials designed to address renal outcomes will be needed for innovative therapies to conclude on their potential benefits in DKD.
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Affiliation(s)
- Seng Kiong Tan
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Diabetes Centre, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Jairo A Pinzon-Cortes
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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23
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Bonora BM, Morieri ML, Marassi M, Cappellari R, Avogaro A, Fadini GP. Improved prediction of long-term kidney outcomes in people with type 2 diabetes by levels of circulating haematopoietic stem/progenitor cells. Diabetologia 2023; 66:2346-2355. [PMID: 37712954 PMCID: PMC10627906 DOI: 10.1007/s00125-023-06002-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/25/2023] [Indexed: 09/16/2023]
Abstract
AIM/HYPOTHESIS We examined whether prediction of long-term kidney outcomes in individuals with type 2 diabetes can be improved by measuring circulating levels of haematopoietic stem/progenitor cells (HSPCs), which are reduced in diabetes and are associated with cardiovascular risk. METHODS We included individuals with type 2 diabetes who had a baseline determination of circulating HSPCs in 2004-2019 at the diabetes centre of the University Hospital of Padua and divided them into two groups based on their median value per ml of blood. We collected updated data on eGFR and albuminuria up to December 2022. The primary endpoint was a composite of new-onset macroalbuminuria, sustained ≥40% eGFR decline, end-stage kidney disease or death from any cause. The analyses were adjusted for known predictors of kidney disease in the population with diabetes. RESULTS We analysed 342 participants (67.8% men) with a mean age of 65.6 years. Those with low HSPC counts (n=171) were significantly older and had a greater prevalence of hypertension, heart failure and nephropathy (45.0% vs 33.9%; p=0.036), as evidenced by lower eGFR and higher albuminuria at baseline. During a median follow-up of 6.7 years, participants with high vs low HSPC counts had lower rates of the composite kidney outcome (adjusted HR 0.69 [95% CI 0.49, 0.97]), slower decline in eGFR and a similar increase in albuminuria. Adding the HSPC information to the risk score of the CKD Prognosis Consortium significantly improved discrimination of individuals with future adverse kidney outcomes. CONCLUSIONS/INTERPRETATION HSPC levels predict worsening of kidney function and improve the identification of individuals with type 2 diabetes and adverse kidney outcomes over and beyond a clinical risk score.
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Affiliation(s)
- Benedetta Maria Bonora
- Department of Medicine, University of Padova, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | | | | | | | - Angelo Avogaro
- Department of Medicine, University of Padova, Padua, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Padua, Italy.
- Veneto Institute of Molecular Medicine, Padua, Italy.
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24
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Pradhan N, Dobre M. Emerging Preventive Strategies in Chronic Kidney Disease: Recent Evidence and Gaps in Knowledge. Curr Atheroscler Rep 2023; 25:1047-1058. [PMID: 38038822 DOI: 10.1007/s11883-023-01172-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is increasingly prevalent worldwide and is associated with increased cardiovascular risk. New therapeutic options to slow CKD progression and reduce cardiovascular morbidity and mortality have recently emerged. This review highlights recent evidence and gaps in knowledge in emerging CKD preventive strategies. RECENT FINDINGS EMPA-Kidney trial found that empagliflozin, a sodium-glucose co-transporter 2 inhibitor (SGLT2i) led to 28% lower risk of progression of kidney disease or death from cardiovascular causes, compared to placebo. This reinforced the previous findings from DAPA-CKD and CREDENCE trials and led to inclusion of SGLT2i as the cornerstone of CKD preventive therapy in both diabetic and non-diabetic CKD. Finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist, slowed diabetic kidney disease progression by 23% compared to placebo in a pool analysis of FIDELIO-DKD and FIGARO-DKD trials. Non-pharmacological interventions, including low protein diet, and early CKD detection and risk stratification strategies based on novel biomarkers have also gained momentum. Ongoing efforts to explore the wealth of molecular mechanisms in CKD, added to integrative omics modeling are well posed to lead to novel therapeutic targets in kidney care. While breakthrough pharmacological interventions continue to improve outcomes in CKD, the heterogeneity of kidney diseases warrants additional investigation. Further research into specific kidney disease mechanisms will facilitate the identification of patient populations most likely to benefit from targeted interventions.
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Affiliation(s)
- Nishigandha Pradhan
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Mirela Dobre
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
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25
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Zhai J, Wang Z, Zhang T, He L, Ma S, Zuo Q, Zhang G, Wang X, Guo Y. Canagliflozin and irbesartan ameliorate renal fibrosis via the TGF-β1/Smad signaling pathway in Dahl salt-sensitive rats. J Int Med Res 2023; 51:3000605231206289. [PMID: 37862678 PMCID: PMC10590049 DOI: 10.1177/03000605231206289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/21/2023] [Indexed: 10/22/2023] Open
Abstract
OBJECTIVES This study assessed the antifibrotic effects of canagliflozin, with or without irbesartan, on renal injury in Dahl salt-sensitive (SS) rats fed a high-salt (HS) diet. METHODS After the preconditioning stage, Dahl SS rats (n = 47) were divided into five experimental groups as follows: low-salt (LS, n = 7), HS (n = 10), HS with canagliflozin (n = 10), HS with irbesartan (n = 10), and HS with canagliflozin and irbesartan (n = 10). RESULTS The HS diet increased systolic blood pressure (SBP), renal fibrosis, fibrotic protein expression, and transforming growth factor-β1 (TGF-β1)/Smad2/3 pathway protein expression compared with the findings in the LS group. Irbesartan reduced SBP and slowed the loss of renal function. Canagliflozin significantly reduced body weight and renal fibrosis and suppressed the TGF-β1/Smad2/3 pathway. The combined therapy exerted better renoprotective effects on all outcome parameters. CONCLUSIONS These results indicate that canagliflozin and irbesartan exert different effects on renal injury in SS hypertensive rats, and the combined regimen could have stronger effects than either monotherapy.
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Affiliation(s)
- Jianlong Zhai
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, China
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, China
| | - Zhongli Wang
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, China
- Department of Medical Examination Center, Hebei General Hospital, Shijiazhuang, China
| | - Tingting Zhang
- Department of Geriatric Cardiology, Hebei General Hospital, Shijiazhuang, China
| | - Lili He
- Department of Geriatric Cardiology, Hebei General Hospital, Shijiazhuang, China
| | - Sai Ma
- Department of Pain Medicine, Hebei General Hospital, Shijiazhuang, China
| | - Qingjuan Zuo
- Department of Geriatric Cardiology, Hebei General Hospital, Shijiazhuang, China
| | - Guorui Zhang
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, China
- Department of Cardiology, The Third Hospital of Shijiazhuang City Affiliated to Hebei Medical University, Shijiazhuang, China
| | - Xinyu Wang
- Department of Internal Medicine, Hebei North University, Zhangjiakou, China
| | - Yifang Guo
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, China
- Department of Geriatric Cardiology, Hebei General Hospital, Shijiazhuang, China
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26
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Miñana G, de la Espriella R, Palau P, Amiguet M, Seller J, García Pinilla JM, Núñez E, Górriz JL, Valle A, Sanchis J, Bayés-Genís A, Núñez J. Early glomerular filtration rate decline is associated with hemoglobin rise following dapagliflozin initiation in heart failure with reduced ejection fraction. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:783-792. [PMID: 36958534 DOI: 10.1016/j.rec.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/08/2023] [Indexed: 03/25/2023]
Abstract
INTRODUCTION AND OBJECTIVES Sodium-glucose cotransporter-2 inhibitors (SGLT2i) induce short-term changes in renal function and hemoglobin. Their pathophysiology is incompletely understood. We aimed to evaluate the relationship between 1- and 3-month estimated glomerular filtration rate (eGFR) and hemoglobin changes following initiation of dapagliflozin in patients with stable heart failure with reduced ejection fraction (HFrEF). METHODS This is a post hoc analysis of a randomized clinical trial that evaluated the effect of dapagliflozin on 1- and 3-month peak oxygen consumption in outpatients with stable HFrEF (DAPA-VO2 trial, NCT04197635). We used linear mixed regression analysis to assess the relationship between eGFR and hemoglobin changes across treatment arms. RESULTS A total of 87 patients were evaluated in this substudy. The mean age was 67.0± 10.5 years, and 21 (24.1%) were women. The mean baseline eGFR and hemoglobin were 66.9±20.7mL/min/1.73m2 and 14.3±1.7g/dL, respectively. Compared with placebo, eGFR did not significantly change at either time points in the dapagliflozin group, but hemoglobin significantly increased at 1 and 3 months. At 1 month, the hemoglobin increase was related to decreases in eGFR only in the dapagliflozin arm (P <.001). At 3 months, there was no significant association in either treatment arms (P=.123). Changes in eGFR were not associated with changes in peak oxygen consumption, quality of life, or natriuretic peptides. CONCLUSIONS In patients with stable HFrEF, 1-month changes in eGFR induced by dapagliflozin are inversely related to changes in hemoglobin. This association was no longer significant at 3 months.
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Affiliation(s)
- Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España
| | - Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España
| | - Patricia Palau
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España
| | - Martina Amiguet
- Departamento de Medicina, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Universitat Jaume I, Castellón, España
| | - Julia Seller
- Servicio de Cardiología, Hospital de Denia, Alicante, España
| | - José Manuel García Pinilla
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, IBIMA, Málaga, España
| | - Eduardo Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España.
| | - José Luis Górriz
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España
| | - Alfonso Valle
- Servicio de Cardiología, Hospital de Denia, Alicante, España
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España
| | - Antoni Bayés-Genís
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Hospital Germans Trias i Pujol, Universitat de Barcelona, Badalona, Barcelona, España
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), España
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Wang J, Guo X, Zou Z, Yu M, Li X, Xu H, Chen Y, Jiao T, Wang K, Ma Y, Jiang J, Liang X, Wang J, Xie C, Zhong Y. Ootheca mantidis mitigates renal fibrosis in mice by the suppression of apoptosis via increasing the gut microbe Akkermansia muciniphila and modulating glutamine metabolism. Biomed Pharmacother 2023; 166:115434. [PMID: 37677965 DOI: 10.1016/j.biopha.2023.115434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023] Open
Abstract
Renal interstitial fibrosis (RIF), a progressive process affecting the kidneys in chronic kidney disease (CKD), currently lacks an effective therapeutic intervention. Traditional Chinese medicine (TCM) has shown promise in reducing RIF and slowing CKD progression. In this study, we demonstrated the dose-dependent attenuation of RIF by Ootheca mantidis (SPX), a commonly prescribed TCM for CKD, in a mouse model of unilateral ureteral obstruction (UUO). RNA-sequencing analysis suggested that SPX treatment prominently downregulated apoptosis and inflammation-associated pathways, thereby inhibiting the fibrogenic signaling in the kidney. We further found that transplantation of fecal microbiota from SPX-treated mice conferred protection against renal injury and fibrosis through suppressing apoptosis in UUO mice, indicating that SPX ameliorated RIF via remodeling the gut microbiota and reducing apoptosis in the kidneys. Further functional exploration of the gut microbiota combined with fecal metabolomics revealed increased levels of some probiotics, including Akkermansia muciniphila (A. muciniphila), and modulations in glutamine-related amino acid metabolism in UUO mice treated with SPX. Subsequent colonization of A. muciniphila and supplementation with glutamine effectively mitigated cell apoptosis and RIF in UUO mice. Collectively, these findings unveil a functionally A. muciniphila- and glutamine-involved gut-renal axis that contributes to the action of SPX, and provide important clue for the therapeutic potential of SPX, A. muciniphila, and glutamine in combatting RIF.
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Affiliation(s)
- Jue Wang
- Division of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China; State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China.
| | - Xiaozhen Guo
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China.
| | - Ziyuan Zou
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China; Center for Fatty Liver, Department of Gastroenterology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Minjun Yu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China; University of Chinese Academy of Sciences, Beijing, China.
| | - Xueling Li
- Division of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
| | - Hualing Xu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China; School of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing, China.
| | - Yiping Chen
- Division of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
| | - Tingying Jiao
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China; Human Phenome Institute, School of Life Sciences, Fudan University, Shanghai, China.
| | - Kanglong Wang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China.
| | - Yuandi Ma
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China; University of Chinese Academy of Sciences, Beijing, China.
| | - Jie Jiang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China; School of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing, China.
| | - Xinyu Liang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China; School of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing, China.
| | - Jiawen Wang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China; Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, China.
| | - Cen Xie
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China; School of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing, China; University of Chinese Academy of Sciences, Beijing, China.
| | - Yifei Zhong
- Division of Nephrology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
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Doğruel H, Atlım HT, Aydemir M, Yılmaz N, Sarı R. Comparative evaluation of clinical outcomes of dapagliflozin and empagliflozin in type-2 diabetes mellitus. Ir J Med Sci 2023; 192:2189-2195. [PMID: 36580225 DOI: 10.1007/s11845-022-03262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/19/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Sodium-glucose transporter 2 (SGLT-2) inhibitors provide additional benefits besides glycemic control. AIM This study aims to compare the clinical outcomes of dapagliflozin and empagliflozin. METHODS This retrospective study evaluated data retrieved from medical records of patients who were under follow-up with the diagnosis of type 2 diabetes mellitus (T2DM) and were started on dapagliflozin or empagliflozin treatment between January 1, 2017, and June 1, 2020. Demographic features, comorbidities, clinical features, duration of diabetes, baseline, and follow-up laboratory test results were recorded. The significance level was set at p < 0.05. RESULTS This study comprised 342 patients who are on the treatment with dapagliflozin (n = 228) or empagliflozin (n = 114). The glycosylated hemoglobin a1c (HBA1C) level was significantly decreased in both the dapagliflozin (8.18-7.59, p < 0.001) and empagliflozin (8.35-7.58, p < 0.001) groups. The urine albumin-to-creatinine ratio (ACR) was also decreased in both groups. A decrease in urine ACR was observed independent of using a renin-angiotensin-aldosterone system (RAAS) blocker both in the whole group and in patients with diabetic nephropathy. The time to addition of a new anti-diabetic agent to the treatment was shorter in the dapagliflozin group (14.4 months vs 17.7 months, p = 0.041, respectively). CONCLUSION Dapagliflozin and empagliflozin are the drugs to choose for renoprotection in diabetics independent of the use of a RAAS blocker. Even the time to addition of a new anti-diabetic agent is longer in the empagliflozin group, head-to-head comparative trials are needed to asess the potential differences in this regard.
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Affiliation(s)
- Hakan Doğruel
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
| | - Hatice Tülüce Atlım
- Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
| | - Mustafa Aydemir
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey.
| | - Nusret Yılmaz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
| | - Ramazan Sarı
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
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Jang HY, Kim IW, Oh JM. Comparative Safety Analysis of Empagliflozin in Type 2 Diabetes Mellitus Patients with Chronic Kidney Disease versus Normal Kidney Function: A Nationwide Cohort Study in Korea. Pharmaceutics 2023; 15:2394. [PMID: 37896154 PMCID: PMC10610004 DOI: 10.3390/pharmaceutics15102394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Empagliflozin has been shown to reduce cardiovascular morbidity and mortality in patients with type 2 diabetes. Various research on its efficacy in patients with chronic kidney disease (CKD) have been actively conducted. So far, few studies have investigated the safety of these adverse effects specifically in Asians with CKD. We aim to address these safety concerns on a patient population of Asian CKD patients using real-world data. METHODS We conducted a retrospective cohort study using health insurance data from the Korean Health Insurance Review & Assessment Service and compared safety outcomes between empagliflozin and sitagliptin in 26,347 CKD patients diagnosed with diabetes. Adverse outcomes, including major adverse cardiac events (MACEs), all-cause mortality, myocardial infarction (MI), stroke, and hospitalization for heart failure (HHF), among others, were assessed. RESULTS Among a 1:1 matched cohort (6170 on empagliflozin, 6170 on sitagliptin), empagliflozin was associated with a significant reduction in MACEs, all-cause mortality, MI, hospitalization for unstable angina, coronary revascularization, HHF, hypoglycemic events, and urinary tract infections, but increased the risk of genital tract infections. No significant changes were observed for transient ischemic attack, acute kidney injury, volume depletion, diabetic ketoacidosis, thromboembolic events, and fractures. CONCLUSIONS The usage of empagliflozin in diabetic CKD patients shows a significant reduction in many adverse outcomes compared to sitagliptin, but with an increased risk of genital tract infections. These findings provide evidence for future clinical decision-making around the use of empagliflozin in Asian CKD patients.
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Affiliation(s)
- Ha Young Jang
- College of Pharmacy, Gachon University, Incheon 21936, Republic of Korea;
| | - In-Wha Kim
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Republic of Korea;
| | - Jung Mi Oh
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Republic of Korea;
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Rangaswami J, Mathew RO. Reducing Kidney Disease Burden in Type 2 Diabetes with SGLT2 Inhibitors: Shifting the Goalposts Upstream. Clin J Am Soc Nephrol 2023; 18:1119-1121. [PMID: 37498620 PMCID: PMC10564343 DOI: 10.2215/cjn.0000000000000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Affiliation(s)
- Janani Rangaswami
- George Washington University School of Medicine, Washington, DC
- VA Medical Center, Washington, DC
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Melzer Cohen C, Schechter M, Rozenberg A, Yanuv I, Sehtman-Shachar DR, Fishkin A, Rosenzweig D, Chodick G, Karasik A, Mosenzon O. Long-Term, Real-World Kidney Outcomes with SGLT2i versus DPP4i in Type 2 Diabetes without Cardiovascular or Kidney Disease. Clin J Am Soc Nephrol 2023; 18:1153-1162. [PMID: 37382938 PMCID: PMC10564349 DOI: 10.2215/cjn.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/11/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Contemporary guidelines recommend the use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) independently of glycemic control in patients with type 2 diabetes and those with kidney disease, with heart failure, or at high risk of cardiovascular disease. Using a large Israeli database, we assessed whether long-term use of SGLT2is versus dipeptidyl peptidase 4 inhibitors (DPP4is) is associated with kidney benefits in patients with type 2 diabetes overall and in those without evidence of cardiovascular or kidney disease. METHODS Patients with type 2 diabetes who initiated SGLT2is or DPP4is between 2015 and 2021 were propensity score-matched (1:1) according to 90 parameters. The kidney-specific composite outcome included confirmed ≥40% decline in eGFR or kidney failure. The kidney-or-death outcome included also all-cause mortality. Risks of outcomes were assessed using Cox proportional hazard regression models. The between-group difference in eGFR slope was also assessed. Analyses were repeated in patients' subgroup lacking evidence of cardiovascular or kidney disease. RESULTS Overall, 19,648 propensity score-matched patients were included; 10,467 (53%) did not have evidence of cardiovascular or kidney disease. Median follow-up was 38 months (interquartile range, 22-55). The composite kidney-specific outcome occurred at an event rate of 6.9 versus 9.5 events per 1000 patient-years with SGLT2i versus DPP4i. The respective event rates of the kidney-or-death outcome were 17.7 versus 22.1. Compared with DPP4is, initiation of SGLT2is was associated with a lower risk for the kidney-specific (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.61 to 0.86; P < 0.001) and kidney-or-death (HR, 0.80; 95% CI, 0.71 to 0.89; P < 0.001) outcomes. The respective HRs (95% CI) in those lacking evidence of cardiovascular or kidney disease were 0.67 (0.44 to 1.02) and 0.77 (0.61 to 0.97). Initiation of SGLT2is versus DPP4is was associated with mitigation of the eGFR slope overall and in those lacking evidence of cardiovascular or kidney disease (mean between-group differences 0.49 [95% CI, 0.35 to 0.62] and 0.48 [95% CI, 0.32 to 0.64] ml/min per 1.73 m 2 per year, respectively). CONCLUSIONS Long-term use of SGLT2is versus DPP4is in a real-world setting was associated with mitigation of eGFR loss in patients with type 2 diabetes, even in those lacking evidence of cardiovascular or kidney disease at baseline.
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Affiliation(s)
- Cheli Melzer Cohen
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dvora R. Sehtman-Shachar
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alisa Fishkin
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Gabriel Chodick
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
- School of Public Health Sackler, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham Karasik
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Scheen AJ. The current role of SGLT2 inhibitors in type 2 diabetes and beyond: a narrative review. Expert Rev Endocrinol Metab 2023; 18:271-282. [PMID: 37154218 DOI: 10.1080/17446651.2023.2210673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Sodium-glucose cotransporter 2 inhibitors (SGLT2is, gliflozins), the most recent oral antihyperglycaemic agents, provide a cardiorenal protection, an effect independent of their glucose-lowering potency. AREAS COVERED The antihyperglycaemic potency of SGLT2is was compared with that of dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, especially when added to metformin monotherapy. Main results of cardiovascular/renal outcome trials with SGLT2is were summarized in different populations: patients with type 2 diabetes mellitus (T2DM) with or without established cardiovascular disease, patients (with or without T2DM) with heart failure (with reduced or preserved left ventricular ejection fraction) and in patients (with or without T2DM) with chronic kidney disease (CKD, including stage 4). Original papers and meta-analyses of these different trials have consistently reported a reduction in hospitalization for heart failure (alone or combined with cardiovascular mortality) and a reduced progression of CKD, with an overall good safety profile. EXPERT OPINION Global use of SGLT2is has increased over time but remains suboptimal despite clinically relevant cardiovascular and renal protection, particularly in patients most likely to benefit. SGLT2is has proven both positive benefit-risk balance and cost-effectiveness in at risk patients. New prospects are expected in other complications, i.e. metabolic-associated fatty liver disease and neurodegenerative disorders.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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Liu J, Shi Y, Diao Y, Zeng X, Fu P. Strategies to Improve Long-Term Outcomes for Patients with Chronic Kidney Disease in China. KIDNEY DISEASES (BASEL, SWITZERLAND) 2023; 9:265-276. [PMID: 37899997 PMCID: PMC10601912 DOI: 10.1159/000530022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/17/2023] [Indexed: 10/31/2023]
Abstract
Background Chronic kidney disease (CKD) is an incurable disease requiring lifelong management. China has a high prevalence of CKD, which disproportionately affects older adults and those with chronic risk factors for CKD development. The rising prevalence of CKD in China places a substantial burden on the general population and the healthcare system. Summary In China, there are currently many unmet needs for patients with CKD and high-risk individuals, resulting from a lack of education and support to reduce risk factors, delayed diagnoses, limited knowledge of CKD among primary-care physicians, and poor access to treatments among some patient populations. An integrated, nationwide approach is required to improve the current situation of CKD management in China. There are currently several national healthcare frameworks in place that focus on new major health policies to prevent disease and encourage people to adopt healthier lifestyles, and while they do not directly target CKD, they may have a positive indirect impact. We explore the unmet needs for patients with CKD in China and discuss the potential strategies that may be required to overcome them. Such strategies include improving physician and patient education, establishing a targeted screening programme, supporting patients to improve self-management behaviours, accelerating the creation of medical consortia and medical satellite centres, and migrating from hospital- to community-based management. In addition to policy-driven strategies, development of novel therapies will be key to providing new solutions for the long-term management of CKD. Key Messages An integrated, nationwide approach is required, incorporating policy-driven changes to the clinical management of CKD, as well as the development of novel CKD treatments.
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Affiliation(s)
- Jing Liu
- Renal Division, West China Hospital of Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
| | - Yunying Shi
- Renal Division, West China Hospital of Sichuan University, Chengdu, China
| | - Yongshu Diao
- Renal Division, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoxi Zeng
- Renal Division, West China Hospital of Sichuan University, Chengdu, China
- West China Biomedical Big Data Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Fu
- Renal Division, West China Hospital of Sichuan University, Chengdu, China
- Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, China
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Calderón Montero A. [Evidence of iSGLT2 in the treatment of chronic kidney disease]. Semergen 2023; 49 Suppl 1:102019. [PMID: 37355296 DOI: 10.1016/j.semerg.2023.102019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/02/2023] [Indexed: 06/26/2023]
Abstract
The prevalence and incidence of chronic kidney disease (CKD) is constantly on the rise and it is foreseeable that in the coming decades it will be the main chronic disease in the developed world. CKD is also one of the main causes of cardiovascular morbidity and mortality, with cardiovascular diseases being the main etiology of CKD, so that one and the other feed back into what is known as the cardiorenal axis. Until five years ago, the only pharmacological treatment that had been shown to modify the course of the disease were inhibitors of the renin angiotensin system. However, in recent years, the development of inhibitors of the sodium glucose cotransporter type2 have led to a revolution in cardiovascular and renal protection, both in diabetic and non-diabetic patients, constituting, at present, the cornerstone in the CKD management.
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Schechter M, Melzer Cohen C, Fishkin A, Rozenberg A, Yanuv I, Sehtman-Shachar DR, Chodick G, Clark A, Abrahamsen TJ, Lawson J, Karasik A, Mosenzon O. Kidney function loss and albuminuria progression with GLP-1 receptor agonists versus basal insulin in patients with type 2 diabetes: real-world evidence. Cardiovasc Diabetol 2023; 22:126. [PMID: 37244998 DOI: 10.1186/s12933-023-01829-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/07/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND In clinical trials enrolling patients with type 2 diabetes (T2D) at high cardiovascular risk, many glucagon-like peptide-1 receptor agonists (GLP-1 RAs) improved albuminuria status and possibly mitigated kidney function loss. However, limited data are available regarding the effects of GLP-1 RAs on albuminuria status and kidney function in real-world settings, including populations with a lower baseline cardiovascular and kidney risk. We assessed the association of GLP-1 RAs initiation with long-term kidney outcomes in the Maccabi Healthcare Services database, Israel. METHODS Adults with T2D treated with ≥ 2 glucose-lowering agents who initiated GLP-1 RAs or basal insulin from 2010 to 2019 were propensity-score matched (1:1) and followed until October 2021 (intention-to-treat [ITT]). In an as-treated (AT) analysis, follow-up was also censored at study-drug discontinuation or comparator-initiation. We assessed the risk of a composite kidney outcome, including confirmed ≥ 40% eGFR loss or end-stage kidney disease, and the risk of new macroalbuminuria. Treatment-effect on eGFR slopes was assessed by fitting a linear regression model per patient, followed by a t-test to compare the slopes between the groups. RESULTS Each propensity-score matched group constituted 3424 patients, 45% women, 21% had a history of cardiovascular disease, and 13.9% were treated with sodium-glucose cotransporter-2 inhibitors at baseline. Mean eGFR was 90.6 mL/min/1.73 m2 (SD 19.3) and median UACR was 14.6 mg/g [IQR 0.0-54.7]. Medians follow-up were 81.1 months (ITT) and 22.3 months (AT). The hazard-ratios [95% CI] of the composite kidney outcome with GLP-1 RAs versus basal insulin were 0.96 [0.82-1.11] (p = 0.566) and 0.71 [0.54-0.95] (p = 0.020) in the ITT and AT analyses, respectively. The respective HRs for first new macroalbuminuria were 0.87 [0.75-0.997] and 0.80 [0.64-0.995]. The use of GLP-1 RA was associated with a less steep eGFR slope compared with basal insulin in the AT analysis (mean annual between-group difference of 0.42 mL/min/1.73 m2/year [95%CI 0.11-0.73]; p = 0.008). CONCLUSION Initiation of GLP-1 RAs in a real-world setting is associated with a reduced risk of albuminuria progression and possible mitigation of kidney function loss in patients with T2D and mostly preserved kidney function.
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Affiliation(s)
- Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, P.O.B 12000, 9112001, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cheli Melzer Cohen
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Alisa Fishkin
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, P.O.B 12000, 9112001, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, P.O.B 12000, 9112001, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, P.O.B 12000, 9112001, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dvora R Sehtman-Shachar
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, P.O.B 12000, 9112001, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gabriel Chodick
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
- School of Public Health Sackler, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | - Avraham Karasik
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, P.O.B 12000, 9112001, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Di Costanzo A, Esposito G, Indolfi C, Spaccarotella CAM. SGLT2 Inhibitors: A New Therapeutical Strategy to Improve Clinical Outcomes in Patients with Chronic Kidney Diseases. Int J Mol Sci 2023; 24:ijms24108732. [PMID: 37240080 DOI: 10.3390/ijms24108732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
The purpose of this manuscript is to review the effects of sodium-glucose cotransport protein 2 inhibitors (SGLT2is) in patients with chronic kidney disease according to basic mechanisms, current recommendations, and future perspectives. Based on growing evidence from randomized, controlled trials, SGLT2is have proven their benefit on cardiac and renal adverse complications, and their indications expanded into the following five categories: glycemic control, reduction in atherosclerotic cardiovascular disease (ASCVD), heart failure, diabetic kidney disease, and nondiabetic kidney disease. Although kidney disease accelerates the progression of atherosclerosis, myocardial disease, and heart failure, so far, no specific drugs were available to protect renal function. Recently, two randomized trials, the DAPA-CKD and EMPA-Kidney, demonstrated the clinical benefit of the SGLT2is dapagliflozin and empagliflozin in improving the outcome in patients with chronic kidney disease. For the consistently positive results in cardiorenal protection, the SGLT2i represents an effective treatment to reduce the progression of kidney disease or death from cardiovascular causes in patients with and without diabetes mellitus.
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Affiliation(s)
- Assunta Di Costanzo
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, 88100 Catanzaro, Italy
| | - Giovanni Esposito
- Division of Cardiology, Dipartimento di Scienze Biomediche Avanzate, Università degli Studi di Napoli "Federico II", 80134 Naples, Italy
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, 88100 Catanzaro, Italy
| | - Carmen Anna Maria Spaccarotella
- Division of Cardiology, Dipartimento di Scienze Biomediche Avanzate, Università degli Studi di Napoli "Federico II", 80134 Naples, Italy
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Khan MS, Rashid AM, Shafi T, Ferreira JP, Butler J. Management of Heart Failure With Reduced Ejection Fraction in Patients With Diabetes Mellitus and Chronic Kidney Disease. Semin Nephrol 2023; 43:151429. [PMID: 37871362 DOI: 10.1016/j.semnephrol.2023.151429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Heart failure (HF), diabetes, and chronic kidney disease (CKD) frequently coexist, with one comorbidity worsening the prognosis of another. β-blockers, angiotensin-receptor-neprilysin inhibitors, renin-angiotensin-aldosterone system inhibitors, mineralocorticoid-receptor antagonists, and sodium-glucose cotransporter-2 inhibitors all have been shown to reduce mortality in patients with HF with reduced ejection fraction. However, their uptake in real-world clinical practice remains low, especially among patients who have multiple other comorbidities such as CKD and diabetes. The management of HF in patients with diabetes and CKD can be especially challenging because these patients typically are older, frail, and have multiple other comorbidities, and guideline-directed medical therapy used in HF potentially can affect renal function acutely and chronically. In this article, we discuss the available evidence for each of the foundational HF therapies in patients with diabetes and CKD, emphasizing the current challenges and outlining future directions to optimize the management of HF among these high-risk patients.
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Affiliation(s)
| | | | - Tariq Shafi
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS
| | - Joao Pedro Ferreira
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, Centre Hospitalier Régional Universitaire (CHRU) Nancy, French Clinical Research Infrastructure Network Investigation Network Initiative Cardiovascular and Renal Clinical Trialist (FCRIN INI-CRCT), Nancy, France
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS; Baylor Scott and White Research Institute, Dallas, TX.
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Fang L, Li G, Ren J, Duan J, Dong J, Liu Z. Integrated analysis for treatment scheme of sodium-glucose cotransporter 2 inhibitors in patients with diabetic kidney disease: a real-world study. Sci Rep 2023; 13:5969. [PMID: 37045938 PMCID: PMC10097684 DOI: 10.1038/s41598-023-33211-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 04/09/2023] [Indexed: 04/14/2023] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are recommended for type 2 diabetes mellitus patients with impaired renal function, but the actual situation of SGLT2i using is unclear. Therefore, in this real-world study, we analyzed the treatment scheme and clinical characteristics of SGLT2i in patients with diabetic kidney disease (DKD). We included DKD patients hospitalized in the First Affiliated Hospital of Zhengzhou University from October 2017 to March 2020. The Apriori algorithm of association rules was used to analysis treatment scheme prescribing SGLT2i and other different combinations of hypoglycemic drugs. SGLT2i was used in 781 (12.3%) of 6336 DKD patients, both number and proportion of patients using SGLT2i increased from 2017 to 2020 (1.9% to 33%). Nighty-eight percent of all DKD patients using SGLT2i were combined with other glucose-lowering agents, and insulin, metformin and alpha-glucosidase inhibitors are most commonly used in combination with hypoglycemic drugs. Multivariate analysis showed that compared with non-SGLT2i group, patients using SGLT2i were associated with younger age, higher BMI, higher HbA1c, preserved kidney function, dyslipidemia and combined with ACEI/ARB and statins. In this real-world study, use of SGLT2i in DKD patients is still low. Most patients performed younger age and in the early stages of chronic kidney disease with poor glycemic control. Clinical inertia should be overcome to fully exert the cardiorenal protective effects of SGLT2 inhibitors, with attention to rational drug use.
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Affiliation(s)
- Li Fang
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
- Henan Province Research Center for Kidney Disease, Zhengzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guangpu Li
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
- Henan Province Research Center for Kidney Disease, Zhengzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingjing Ren
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China
- Henan Province Research Center for Kidney Disease, Zhengzhou, China
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiayu Duan
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China.
- Henan Province Research Center for Kidney Disease, Zhengzhou, China.
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China.
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Jiancheng Dong
- Clinical Research Center of Big-Data, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Zhangsuo Liu
- Department of Integrated Traditional and Western Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
- Research Institute of Nephrology, Zhengzhou University, Zhengzhou, China.
- Henan Province Research Center for Kidney Disease, Zhengzhou, China.
- Key Laboratory of Precision Diagnosis and Treatment for Chronic Kidney Disease in Henan Province, Zhengzhou, China.
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Krishnan A, Shankar M, Lerma EV, Wiegley N. Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors and CKD: Are You a #Flozinator? Kidney Med 2023; 5:100608. [PMID: 36915368 PMCID: PMC10006698 DOI: 10.1016/j.xkme.2023.100608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Sodium/glucose cotransporter 2 (SGLT2) inhibitors have rapidly emerged as a novel therapy to reduce the rate of progression of chronic kidney disease (CKD). With humble beginnings in the 19th century for treating malaria, this class of drugs initially developed for the treatment of diabetes has now revolutionized the management of heart failure and CKD. SGLT2 inhibitors trigger glucosuria, thus modestly improving glycemic control. In addition, they have pleiotropic effects, such as reducing intraglomerular pressure and improving tubuloglomerular feedback, which lead to their beneficial effects on CKD progression. Recent data from randomized controlled trials have demonstrated the efficacy of this class of drugs in CKD. We briefly review the evidence from major trials on SGLT2 inhibitors in CKD, discuss the mechanisms of action and provide an overview of the safe and successful prescription of these medications.
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Affiliation(s)
| | - Mythri Shankar
- Department of Nephrology, Institute of Nephro-urology, Bengaluru, India
| | - Edgar V. Lerma
- Department of Medicine; University of Illinois at Chicago; Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Nasim Wiegley
- Department of Medicine, University of California, Davis School of Medicine, Sacramento, California
- Address for Correspondence: Nasim Wiegley, MD, University of California, Davis School of Medicine, Sacramento, CA.
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Morton JI, Marquina C, Shaw JE, Liew D, Polkinghorne KR, Ademi Z, Magliano DJ. Projecting the incidence and costs of major cardiovascular and kidney complications of type 2 diabetes with widespread SGLT2i and GLP-1 RA use: a cost-effectiveness analysis. Diabetologia 2023; 66:642-656. [PMID: 36404375 PMCID: PMC9947091 DOI: 10.1007/s00125-022-05832-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/07/2022] [Indexed: 11/22/2022]
Abstract
AIMS/HYPOTHESIS Whether sodium-glucose co-transporter 2 inhibitors (SGLT2is) or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are cost-effective based solely on their cardiovascular and kidney benefits is unknown. We projected the health and economic outcomes due to myocardial infarction (MI), stroke, heart failure (HF) and end-stage kidney disease (ESKD) among people with type 2 diabetes, with and without CVD, under scenarios of widespread use of these drugs. METHODS We designed a microsimulation model using real-world data that captured CVD and ESKD morbidity and mortality from 2020 to 2040. The populations and transition probabilities were derived by linking the Australian Diabetes Registry (1.1 million people with type 2 diabetes) to hospital admissions databases, the National Death Index and the ESKD Registry using data from 2010 to 2019. We modelled four interventions: increase in use of SGLT2is or GLP-1 RAs to 75% of the total population with type 2 diabetes, and increase in use of SGLT2is or GLP-1 RAs to 75% of the secondary prevention population (i.e. people with type 2 diabetes and prior CVD). All interventions were compared with current use of SGLT2is (20% of the total population) and GLP-1 RAs (5% of the total population). Outcomes of interest included quality-adjusted life years (QALYs), total costs (from the Australian public healthcare perspective) and the incremental cost-effectiveness ratio (ICER). We applied 5% annual discounting for health economic outcomes. The willingness-to-pay threshold was set at AU$28,000 per QALY gained. RESULTS The numbers of QALYs gained from 2020 to 2040 with increased SGLT2i and GLP-1 RA use in the total population (n=1.1 million in 2020; n=1.5 million in 2040) were 176,446 and 200,932, respectively, compared with current use. Net cost differences were AU$4.2 billion for SGLT2is and AU$20.2 billion for GLP-1 RAs, and the ICERs were AU$23,717 and AU$100,705 per QALY gained, respectively. In the secondary prevention population, the ICERs were AU$8878 for SGLT2is and AU$79,742 for GLP-1 RAs. CONCLUSIONS/INTERPRETATION At current prices, use of SGLT2is, but not GLP-1 RAs, would be cost-effective when considering only their cardiovascular and kidney disease benefits for people with type 2 diabetes.
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Affiliation(s)
- Jedidiah I Morton
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Clara Marquina
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Kevan R Polkinghorne
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Nephrology, Monash Health, Clayton, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Dianna J Magliano
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Alkabbani W, Gamble JM. Prescribing Trends of the Sodium-Glucose Cotransporter-2 Inhibitors Among Different Physician Specialties in Canada (2015-2021). Can J Diabetes 2023; 47:153-161. [PMID: 36481264 DOI: 10.1016/j.jcjd.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/21/2022] [Accepted: 11/01/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Landmark clinical trials have shown the sodium-glucose cotransporter-2 (SGLT-2) inhibitors to have cardiorenal benefits beyond their glucose-lowering effect. Clinical guidelines now recommend their use in patients with chronic kidney disease or heart failure, with or without type 2 diabetes, potentially affecting prescribing patterns among physician specialties. METHODS Using monthly projected total retail dispensed prescription data from IQVIA's CompuScript database, we assessed trends in prescribing SGLT-2 inhibitors among 6 prescriber specialities from 2015 to 2021 in Canada. We assessed these trends at the class, agent, and dose level using joinpoint regression. RESULTS From 2015 to 2021, the projected total retail dispensed prescriptions of SGLT-2 inhibitors from all prescribers increased. Relative to other prescribers, >60% of SGLT-2 inhibitor prescriptions were written by general practitioners or family physicians. The percentage of prescriptions from endocrinologists decreased (average annual percent change: mean, -10.8; 95% confidence interval [CI], -12.2% to -9.4%), whereas a dramatic increase was observed for cardiologists (mean, 44.1%, 95% CI, 32.9 to 56.2). The percentage from nephrologists also increased, albeit not statistically significant (mean, 12.4; 95% CI, -0.5 to 27.1). Significant changes in the agent and dose of SGLT-2 inhibitor prescribed were also observed among cardiologists and nephrologists. CONCLUSIONS Between 2015 and 2021, there was a steady increase in the proportion of SGLT-2 inhibitor prescriptions from cardiologists and nephrologists, reflecting emerging evidence and guideline recommendations.
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Affiliation(s)
- Wajd Alkabbani
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
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42
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Lee CH, Lui DTW, Cheung CYY, Fong CHY, Yuen MMA, Chow WS, Xu A, Lam KSL. Circulating thrombospondin-2 level for identifying individuals with rapidly declining kidney function trajectory in type 2 diabetes: a prospective study of the Hong Kong West Diabetes Registry. Nephrol Dial Transplant 2023:gfad034. [PMID: 36857285 DOI: 10.1093/ndt/gfad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Thrombospondin-2 (TSP2) is a matricellular protein with tissue expression induced by hyperglycaemia. TSP2 has been implicated in non-diabetic renal injury in preclinical studies and high circulating levels were associated with worse kidney function in cross-sectional clinical studies. Therefore, we investigated the prospective associations of circulating TSP2 level with kidney function decline and the trajectories of estimated glomerular filtration rate (eGFR) in type 2 diabetes. METHODS Baseline serum TSP2 level was measured in 5471 patients with type 2 diabetes to evaluate its association with incident eGFR decline, defined as ≥ 40% sustained eGFR decline, using multivariable Cox regression analysis. Among participants with relatively preserved kidney function (Baseline eGFR ≥ 60 ml/min/1.73m2), joint latent class modelling was employed to identify three different eGFR trajectories. Their associations with baseline serum TSP2 was evaluated using multinomial logistic regression analysis. The predictive performance of serum TSP2 level was examined using time-dependent c-statistics and calibration statistics. RESULTS Over a median follow-up of 8.8 years, 1083 patients (19.8%) developed eGFR decline. Baseline serum TSP2 level was independently associated with incident eGFR decline (HR 1.21, 95%CI 1.07-1.37, P = 0.002). With internal validation, incorporating serum TSP2 to a model of clinical risk factors including albuminuria led to significant improvement in c-statistics from 83.9 to 84.4 (P < 0.001). Among patients with eGFR ≥ 60 ml/min/1.73m2, baseline serum TSP2 level was independently associated with a rapidly declining eGFR trajectory (HR 1.63, 95%CI 1.26-2.10, P < 0.001). CONCLUSION Serum TSP2 level was independently associated with incident eGFR decline, particularly a rapidly declining trajectory, in type 2 diabetes.
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Affiliation(s)
- Chi-Ho Lee
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
- State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong
| | - David Tak-Wai Lui
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Chloe Yu-Yan Cheung
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Carol Ho-Yi Fong
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | | | - Wing-Sun Chow
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Aimin Xu
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
- State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong
| | - Karen Siu-Ling Lam
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
- State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong
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Isidto R, Danguilan R, Naidas O, Vilanueva R, Arakama MH, Paraiso LM. Emerging Role of Sodium-Glucose Co-Transporter 2 Inhibitors for the Treatment of Chronic Kidney Disease. Int J Nephrol Renovasc Dis 2023; 16:43-57. [PMID: 36852177 PMCID: PMC9960786 DOI: 10.2147/ijnrd.s387262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/24/2022] [Indexed: 02/25/2023] Open
Abstract
Chronic kidney disease is one of the leading causes of morbidity and mortality in the Philippines. It is associated with a growing health burden as many patients progress to end-stage renal disease. Until recently, therapeutic options for the management of chronic kidney disease were limited. Sodium-glucose co-transporter 2 inhibitors offer an alternative therapeutic approach for patients with chronic kidney disease. Several trials have shown renal benefits with sodium-glucose co-transporter 2 inhibitors in patients with cardiovascular disease with and without type 2 diabetes and across a range of estimated glomerular filtration rate levels. In the Philippines, the sodium-glucose co-transporter 2 inhibitors dapagliflozin and canagliflozin are approved for the prevention of new and worsening nephropathy in type 2 diabetes. With emerging treatment options, an urgent need exists for guidance on the management of chronic kidney disease within the Philippines. In this review, we focus on the putative renal-protective mechanisms of sodium-glucose co-transporter 2 inhibitors, including effects on tubuloglomerular feedback, albuminuria, endothelial function, erythropoiesis, uric acid levels, renal oxygen demand, and hypoxia. Furthermore, we discuss the findings of recent large clinical trials using sodium-glucose co-transporter 2 inhibitors in patients with chronic kidney disease and diabetic kidney disease, summarize safety aspects, and outline the practical management of patients with chronic kidney disease in the Philippines.
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Affiliation(s)
- Rey Isidto
- HealthLink Medical, Surgical, Dental Clinics and Diagnostic Center, Iloilo City, Iloilo, Philippines,Correspondence: Rey Isidto, HealthLink Medical, Surgical, Dental Clinics and Diagnostic Center, Iloilo City, Iloilo, Philippines, Tel +63 9178406232, Fax +63 33 3303863, Email
| | - Romina Danguilan
- Department of Adult Nephrology, National Kidney and Transplant Institute, Quezon City, Manila, Philippines
| | - Oscar Naidas
- Department of Adult Nephrology, St. Luke’s Medical Center, Quezon City, Manila, Philippines
| | - Russell Vilanueva
- Department of Adult Nephrology, National Kidney and Transplant Institute, Quezon City, Manila, Philippines
| | - Mel-Hatra Arakama
- Department of Adult Nephrology, National Kidney and Transplant Institute, Quezon City, Manila, Philippines
| | - Layla Marie Paraiso
- Department of Adult Nephrology, National Kidney and Transplant Institute, Quezon City, Manila, Philippines
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Colbert GB, Madariaga HM, Gaddy A, Elrggal ME, Lerma EV. Empagliflozin in Adults with Chronic Kidney Disease (CKD): Current Evidence and Place in Therapy. Ther Clin Risk Manag 2023; 19:133-142. [PMID: 36756278 PMCID: PMC9901477 DOI: 10.2147/tcrm.s398163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
Chronic kidney disease guidelines and disease modifying therapy have seen a dramatic shift in the last 5 years. The SGLT2 inhibitor class of medications has been catapulted from hyperglycemia management medications, to cardiovascular and kidney disease improvement therapies. Multiple trials looking at dedicated cardiovascular and kidney endpoints have resulted in favorable results. This review will target empagliflozin and the exciting journey that it has taken along this path. Empagliflozin has been studied for hyperglycemia, cardiovascular, and kidney hard outcome endpoints. Both patients with diabetes and without have been rigorously studied and shown surprising results. The major implications for patients on empagliflozin will be shown. Future studies and directions are highly anticipated to add to the growing knowledge of the SGLT2 inhibitor class, as well as discover possibilities for new disease states to benefit from empagliflozin.
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Affiliation(s)
- Gates B Colbert
- Texas A&M University College of Medicine at Dallas, Dallas, TX, USA,Correspondence: Gates B Colbert, Department of Internal Medicine, Baylor University Medical Center at Dallas, 3417 Gaston Ave, Suite 875, Dallas, TX, 75246, USA, Tel +1-972-388-5970, Email
| | - Hector M Madariaga
- Department of Internal Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Anna Gaddy
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohamed E Elrggal
- Division of Nephrology, Kidney and Urology Center, Alexandria, Egypt
| | - Edgar V Lerma
- Section of Nephrology, University of Illinois at Chicago, Chicago, IL, USA
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Kim DJ, Sheu WH, Chung W, Yabe D, Ha KH, Nangaku M, Tan EC, Node K, Yasui A, Lei W, Lee S, Saarelainen L, Deruaz‐Luyet A, Kyaw MH, Seino Y. Empagliflozin is associated with lower risk of cardiovascular events and all-cause mortality in routine care in East Asia: Results from the EMPRISE study. J Diabetes Investig 2023; 14:417-428. [PMID: 36716212 PMCID: PMC9951576 DOI: 10.1111/jdi.13959] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 11/18/2022] [Accepted: 11/30/2022] [Indexed: 01/31/2023] Open
Abstract
AIMS/INTRODUCTION The EMPA-REG OUTCOME® trial demonstrated benefits of empagliflozin, a sodium-glucose cotransporter-2 inhibitor (SGLT2i), on cardiovascular, renal outcomes and all-cause mortality in patients with type 2 diabetes and established cardiovascular disease. The EMPRISE study program evaluates how these effects translate in a broad population of patients with type 2 diabetes in routine clinical care across countries. MATERIALS AND METHODS The study included patients ≥18 years with type 2 diabetes initiating empagliflozin or any dipeptidyl peptidase-4 inhibitors (DPP-4i) from large administrative databases in Japan, South Korea, and Taiwan. Propensity score-matched (1:1) 'as-treated' analyses comparing the risk of cardiovascular outcomes and all-cause mortality between empagliflozin and DPP-4i use were performed in each country. Pooled hazard ratios (pHR) with 95% confidence intervals (CI) were computed using random effects meta-analysis models comparing both empagliflozin and SGLT2i with DPP-4i use, respectively. Intention-to-treat and subgroup analyses in patients with/without cardiovascular disease and in patients receiving 10 mg empagliflozin were performed. RESULTS The study included 28,712 and 70,233 matched patient pairs for empagliflozin/DPP-4i and SGLT2i/DPP-4i analyses, respectively. The risk of composite outcomes including (i) hospitalization for heart failure (HHF) and all-cause mortality was lower with empagliflozin (pHR 0.76, 95% CI 0.67-0.86) and SGLT2i (0.71, 0.65-0.77); (ii) combined myocardial infarction, stroke, and all-cause mortality was also lower with empagliflozin (0.74, 0.61-0.88) and SGLT2i (0.69, 0.60-0.78) compared to DPP-4i. The intention-to-treat and three subgroup analyses were consistent with results of the main analyses. CONCLUSIONS The results suggest that both empagliflozin and SGLT2i compared with DPP-4i are associated with a lower risk of cardiovascular events and all-cause mortality in routine clinical care in East Asia.
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Affiliation(s)
- Dae Jung Kim
- Department of Endocrinology and MetabolismAjou University School of MedicineSuwonSouth Korea
| | - Wayne H‐H Sheu
- Division of Endocrinology and MetabolismTaipei Veterans General HospitalTaipeiTaiwan
| | - Wook‐Jin Chung
- Department of Cardiovascular MedicineGachon University Gil Medical CenterIncheonSouth Korea
| | - Daisuke Yabe
- Kansai Electric Power Medical Research InstituteKobeJapan,Department of Diabetes, Metabolism and Endocrinology/Department of Rheumatology and Clinical ImmunologyGifu University Graduate School of MedicineGifuJapan,Center for Healthcare Information TechnologyTokai National Higher Education and Research SystemNagoyaJapan,Division of Metabolism and Molecular MedicineKobe University Graduate School of MedicineKobeJapan
| | - Kyoung Hwa Ha
- Department of Endocrinology and MetabolismAjou University School of MedicineSuwonSouth Korea
| | - Masaomi Nangaku
- Division of Nephrology and EndocrinologyThe University of TokyoTokyoJapan
| | - Elise Chia‐Hui Tan
- National Research Institute of Chinese Medicine, Ministry of Health and WelfareTaipeiTaiwan,Institute of Hospital and Healthcare AdministrationNational Yang‐Ming UniversityTaipeiTaiwan
| | - Koichi Node
- Department of Cardiovascular MedicineSaga UniversitySagaJapan
| | | | - Weiyu Lei
- Boehringer Ingelheim Taiwan LtdTaipeiTaiwan
| | - Sunwoo Lee
- Boehringer Ingelheim Korea LtdSeoulSouth Korea
| | | | | | - Moe H Kyaw
- Boehringer Ingelheim Pharmaceuticals, Inc.RidgefieldConnecticutUSA
| | - Yutaka Seino
- Kansai Electric Power Medical Research InstituteKobeJapan,Kansai Electric Power HospitalOsakaJapan
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Akiyama H, Nishimura A, Morita N, Yajima T. Evolution of sodium-glucose co-transporter 2 inhibitors from a glucose-lowering drug to a pivotal therapeutic agent for cardio-renal-metabolic syndrome. Front Endocrinol (Lausanne) 2023; 14:1111984. [PMID: 36793276 PMCID: PMC9922689 DOI: 10.3389/fendo.2023.1111984] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/18/2023] [Indexed: 01/31/2023] Open
Abstract
Cardio-renal-metabolic (CRM) syndrome, which involves type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), and heart failure (HF), is a serious healthcare issue globally, with high morbidity and mortality. The disorders that comprise CRM syndrome are independent can mutually affect and accelerate the exacerbation of each other, thereby substantially increasing the risk of mortality and impairing quality of life. To manage CRM syndrome by preventing vicious interactions among individual disorders, a holistic treatment approach that can simultaneously address multiple disorders underpinning CRM syndrome is of great importance. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) lower blood glucose levels by inhibiting glucose reabsorption in the renal proximal tubule and were first indicated for the treatment of T2DM. Several cardiovascular outcome trials have demonstrated that SGLT2i not only lower blood glucose but also reduce the risk of hospitalization for HF and worsening renal function in patients with T2DM. Results have also suggested that the observed cardiorenal benefits of SGLT2i may be independent of their blood glucose-lowering effects. Several randomized controlled trials subsequently assessed the efficacy and safety of SGLT2i in patients without T2DM, and revealed considerable benefits of SGLT2i treatment against HF and CKD, regardless of the presence of T2DM. Thus, SGLT2i have become an essential therapeutic option to prevent the onset, slow the progression, and improve the prognosis of CRM syndrome. This review assesses the evolution of SGLT2i from a glucose-lowering drug to a therapeutic agent for CRM syndrome by evaluating epoch-making clinical studies, including randomized control trials and real-world studies.
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Affiliation(s)
| | - Akihiro Nishimura
- Medical Affairs, AstraZeneca K.K., Osaka, Japan
- Department of Internal Medicine, Urayasu Central Hospital, Chiba, Japan
| | - Naru Morita
- Medical Affairs, AstraZeneca K.K., Osaka, Japan
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Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) were originally developed as antidiabetic agents, with cardiovascular (CV) outcome trials demonstrating improved CV outcomes in patients with type 2 diabetes mellitus (T2D). Secondary analyses of CV outcome trials and later dedicated kidney outcome trials consistently reported improved kidney-related outcomes independent of T2D status and across a range of kidney function and albuminuria. Importantly, SGLT2 inhibitors are generally safe and well tolerated, with clinical trials and real-world analyses demonstrating a decrease in the risk of acute kidney injury. The kidney protective effects of SGLT2 inhibitors generally extend across different members of the class, possibly on the basis of hemodynamic, metabolic, anti-inflammatory, and antifibrotic mechanisms. In this review, we summarize the effects of SGLT2 inhibitors on kidney outcomes in diverse patient populations.
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Affiliation(s)
- Atit Dharia
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Abid Khan
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vikas S Sridhar
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Zanchi A, Jehle AW, Lamine F, Vogt B, Czerlau C, Bilz S, Seeger H, de Seigneux S. Diabetic kidney disease in type 2 diabetes: a consensus statement from the Swiss Societies of Diabetes and Nephrology. Swiss Med Wkly 2023; 153:40004. [PMID: 36652726 DOI: 10.57187/smw.2023.40004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Diabetic kidney disease is highly prevalent in patients with type 2 diabetes and is a major cause of end-stage renal disease in Switzerland. Patients with diabetic kidney disease are among the most complex patients in diabetes care. They require a multifactorial and multidisciplinary approach with the goal to slow the decline in glomerular filtration rate (GFR) and cardiovascular morbidity. With this consensus we propose an evidence-based guidance to health care providers involved in the care of type 2 diabetic patients with diabetic kidney disease.First, there is a need to increase physician awareness and improve screening for diabetic kidney disease as early intervention may improve clinical outcomes and the financial burden. Evaluation of estimated GFR (eGFR) and spot urine albumin/creatinine ratio is recommended at least annually. Once it is diagnosed, glucose control and optimisation of blood pressure control with renin-angiotensin system blockers have been recommended as mainstay management of diabetic kidney disease for more than 20 years. Recent, high quality randomised controlled trials have shown that sodium-glucose cotransporter-2 (SGLT2) inhibition slows eGFR decline and cardiovascular events beyond glucose control. Likewise, mineralocorticoid receptor antagonism with finerenone has cardiorenal protective effects in diabetic kidney disease. Glucagon-like peptide-1 (GLP1) receptor agonists improve weight loss if needed, and decrease albuminuria and cardiovascular morbidity. Lipid control is also important to decrease cardiovascular events. All these therapies are included in the treatment algorithms proposed in this consensus. With advancing kidney failure, other challenges may rise, such as hyperkalaemia, anaemia and metabolic acidosis, as well as chronic kidney disease-mineral and bone disorder. These different topics and treatment strategies are discussed in this consensus. Finally, an update on diabetes management in renal replacement therapy such as haemodialysis, peritoneal dialysis and renal transplantation is provided. With the recent developments of efficient therapies for diabetic kidney disease, it has become evident that a consensus document is necessary. We are optimistic that it will significantly contribute to a high-quality care for patients with diabetic kidney disease in Switzerland in the future.
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Affiliation(s)
- Anne Zanchi
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Service of Endocrinology, Diabetes and Metabolism, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Andreas W Jehle
- Department of Internal Medicine, Hirslanden Klinik St. Anna, Lucerne, Switzerland.,Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Faiza Lamine
- Service of Endocrinology, Diabetes and Metabolism, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Unit of Diabetes and Endocrinology, Department of Internal Medicine, Riviera-Chablais Hospital (HRC), Rennaz, Switzerland
| | - Bruno Vogt
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Cecilia Czerlau
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Stefan Bilz
- Internal Medicine and Endocrinology, Kantonsspital St Gallen, Switzerland
| | - Harald Seeger
- Division of Nephrology, University Hospital Zurich, Switzerland
| | - Sophie de Seigneux
- Service of Nephrology and Hypertension, Department of Medicine, Geneva University Hospital, Switzerland
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Au PCM, Tan KCB, Lam DCL, Cheung BMY, Wong ICK, Kwok WC, Sing CW, Cheung CL. Association of Sodium-Glucose Cotransporter 2 Inhibitor vs Dipeptidyl Peptidase-4 Inhibitor Use With Risk of Incident Obstructive Airway Disease and Exacerbation Events Among Patients With Type 2 Diabetes in Hong Kong. JAMA Netw Open 2023; 6:e2251177. [PMID: 36648944 PMCID: PMC9857182 DOI: 10.1001/jamanetworkopen.2022.51177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
IMPORTANCE Patients with diabetes are at higher risk for obstructive airway disease (OAD). In recent meta-analyses of post hoc analyses of cardiorenal trials, sodium-glucose cotransporter 2 inhibitors (SGLT2Is) were suggested to reduce the risk of OAD adverse events. However, a clinical investigation of this association is warranted. OBJECTIVE This study aimed to investigate the association of SGLT2I use vs dipeptidyl peptidase-4 inhibitor (DPP4I) use with OAD incidence and exacerbation events in patients with type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study used electronic health data from a territory-wide electronic medical database in Hong Kong. Data were collected for patients with type 2 diabetes who were prescribed SGLT2Is or DPP4Is between January 1, 2015, and December 31, 2018. Patients were followed for a median of 2.2 years between January 1, 2015, and December 31, 2020. A prevalent new-user design was adopted to match patients based on previous exposure to the study drugs. Propensity score matching was used to balance baseline characteristics. EXPOSURES Patients with type 2 diabetes using SGLT2Is (exposure of interest) or DPP4Is (active comparator). MAIN OUTCOMES AND MEASURES The main outcomes were the first incidence of OAD and the count of OAD exacerbations. The risk of incident OAD was estimated using a Cox proportional hazards regression model. The rate of exacerbations was estimated using zero-inflated Poisson regression. Statistical analysis was performed on November 13, 2022. RESULTS This study included 30 385 patients. The propensity score-matched non-OAD cohort (incidence analysis) consisted of 5696 SGLT2I users and 22 784 DPP4I users, while the matched OAD cohort (exacerbations analysis) comprised 381 SGLT2I users and 1524 DPP4I users. At baseline, 56% of patients in the non-OAD cohort were men and the mean (SD) age was 61.2 (9.9) years; 51% of patients in the OAD cohort were men and the mean age was 62.2 (10.8) years. Compared with DPP4I use, SGLT2I use was associated with a lower risk of incident OAD (hazard ratio, 0.65 [95% CI, 0.54-0.79]; P < .001) and a lower rate of exacerbations (rate ratio, 0.54 [95% CI, 0.36-0.83]; P = .01). The associations were consistent in sex subgroup analysis. CONCLUSIONS AND RELEVANCE The findings of this retrospective cohort study of patients with type 2 diabetes in Hong Kong suggest that SGLT2I use was associated with a reduced risk of incident OAD and a lower rate of exacerbations in a clinical setting compared with DPP4I use. These findings further suggest that SGLT2Is may provide additional protective effects against OAD for patients with type 2 diabetes and that further investigation is warranted.
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Affiliation(s)
- Philip C. M. Au
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Kathryn C. B. Tan
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - David C. L. Lam
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Bernard M. Y. Cheung
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Ian C. K. Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Pak Shek Kok, Hong Kong Special Administrative Region, China
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
| | - Wang Chun Kwok
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Chor-Wing Sing
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Pak Shek Kok, Hong Kong Special Administrative Region, China
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Pak Shek Kok, Hong Kong Special Administrative Region, China
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Gonzalez Perez A, Vizcaya D, Sáez ME, Lind M, Garcia Rodriguez LA. Cardiovascular and renal outcomes among patients with type 2 diabetes using SGLT2 inhibitors added to metformin: a population-based cohort study from the UK. BMJ Open Diabetes Res Care 2023; 11:11/1/e003072. [PMID: 36596641 PMCID: PMC9814995 DOI: 10.1136/bmjdrc-2022-003072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/26/2022] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Large numbers of patients with type 2 diabetes receive treatment with a sodium-glucose co-transporter-2 inhibitor (SGLT2i). We investigated whether the cardiorenal preventative effects found in clinical trials are also seen in clinical practice where patient characteristics and adherence to treatment differ. RESEARCH DESIGN AND METHODS Using UK primary care electronic health records, we followed two cohorts of patients with type 2 diabetes prescribed metformin: SGLT2is (N=12 978) and a matched comparator of patients not using an SGLT2i at the start of follow-up (N=44 286). Independent follow-ups were performed to identify the study outcomes: cardiovascular (CV) composite (comprising non-fatal myocardial infarction (MI)/ischemic stroke (IS) requiring hospitalization and CV death), severe renal disease, and all-cause mortality. Cox regression was used to estimate adjusted HRs. RESULTS Mean follow-up was 2.3 years (SGLT2i cohort) and 2.1 years (comparison cohort). Mean age was 59.6 years (SD ±10.2, SGLT2i cohort) and 60.4 years (SD ±10.0, comparison cohort). SGLT2i new users were associated with a reduced risk of the CV composite (HR 0.75, 95% CI: 0.61 to 0.93), severe renal disease (HR 0.55, 95% CI: 0.46 to 0.67), and all-cause mortality (HR 0.56, 95% CI: 0.49 to 0.63), with risk reductions similar irrespective of baseline chronic kidney disease. Reduced risks were seen for IS (HR 0.51, 95% CI: 0.36 to 0.74) but not MI (HR 0.98, 95% CI: 0.74 to 1.28). Results were consistent in sensitivity analyses. CONCLUSIONS In this population-based study, SGLT2is were associated with significant CV, renal and survival benefits among individuals with type 2 diabetes on metformin; the CV benefit was driven by a reduced risk of ischemic stroke.
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Affiliation(s)
- Antonio Gonzalez Perez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
- Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain
- Pharmacoepidemiology Research Group, Institute for Health Research (IRYCIS), Madrid, Spain
| | | | - Maria E Sáez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
- Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain
| | - Marcus Lind
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, NU Hospital Organization, Uddevalla, Sweden
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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