Dedicated kidney disease-focused outcome trials with sodium-glucose cotransporter-2 inhibitors: Lessons from CREDENCE and expectations from DAPA-HF, DAPA-CKD, and EMPA-KIDNEY

Managing Diabetes in Older Adults: Current Approaches in Long-Term Care Facilities

PURPOSE OF REVIEW

This narrative review aims to explore the literature on advancements in diabetes management within long-term care facilities (LTCFs). Managing chronic diseases like diabetes in LTCFs is particularly challenging due to the dynamic nature of these environments and the significant changes they have undergone over the past decade. Various factors, including rising care costs and government regulations, influence the quality-of-care residents receive in these settings.

RECENT FINDINGS

Many diabetes medications have not been extensively studied in LTCFs, and high-risk medications such as sulfonylureas and sliding scale insulin are still in use, potentially increasing the risk of morbidity and mortality among residents. Additionally, the adoption of diabetes technologies, such as continuous glucose monitors (CGMs) and insulin pumps, remains limited in LTCFs. Despite the high prevalence of diabetes, significant research gaps persist. Diabetes technologies have the potential to greatly improve diabetes management and outcomes for residents. However, more research is needed to evaluate their efficacy and safety in long-term care settings. Furthermore, there is a pressing need to address the gap in staff training on the use of these technologies. Closing these research gaps is essential for developing evidence-based guidelines and improving the quality of diabetes care in LTCFs.

Cost-effectiveness of dapagliflozin plus standard treatment compared to standard therapy for the management of chronic kidney disease in Colombia

BACKGROUND

The DAPA-CKD study showed that dapagliflozin added to standard treatment reduced the risk of chronic kidney disease progression, and death from renal or cardiovascular causes compared to placebo.

OBJECTIVE

Assess the cost-effectiveness of dapagliflozin and standard treatment versus standard treatment alone for chronic kidney disease within the Colombian health system.

METHODS

We employed a Markov model based on the DAPA-CKD study, tailored to the Colombian scenario. The model forecasted hospitalizations for heart failure, overall and cardiovascular mortality, and chronic kidney disease progression over a 10-year horizon with a 5% discount rate.

RESULTS

Dapagliflozin combined with standard treatment is a cost-effective intervention in treating stage 2-4 CKD. In the base case, the ICER was US $5,366, below 1 GDP (US $6.558) per capita. This was consistent in the sensitivity analyses.

CONCLUSION

Our study showed that dapagliflozin, when combined with standard treatment, is cost-effective against standard treatment alone, aligning with Colombia's willingness-to-pay threshold.

SA-β-Gal in Kidney Tubules as a Predictor of Renal Outcome in Patients with Chronic Kidney Disease

Cellular senescence has emerged as an important driver of aging and age-related disease in the kidney. The activity of β-galactosidase at pH 6 (SA-β-Gal) is a classic maker of senescence in cellular biology; however, the predictive role of kidney tissue SA-β-Gal on eGFR loss in chronic kidney disease (CKD) is still not understood. We retrospectively studied the expression of SA-β-Gal in kidney biopsies obtained in a cohort [n = 22] of incident patients who were followed up for 3 years as standard of care. SA-β-Gal staining was approximately fourfold higher in the tubular compartment of patients with CKD vs. controls [26.0 ± 9 vs. 7.4 ± 6% positive tubuli in patients vs. controls; p < 0.025]. Tubular expressions of SA-β-Gal, but not proteinuria, at the time of biopsy correlated with eGFR loss at the follow up; moreover, SA-β-Gal expression in more than 30% of kidney tubules was associated with fast progressive kidney disease. In conclusion, our study shows that SA-β-Gal is upregulated in the kidney tubular compartment of adult patients affected by CKD and suggests that tubular SA-β-Gal is associated with accelerated loss of renal function.

Indicators of biochemical control of diabetes mellitus during limited availability of health service in the context of hypoglycemic therapy

OBJECTIVE

Aim: Type 2 diabetes mellitus (T2DM) is a widespread disease that leads to many complications if not adequately controlled. The pandemic and its limitations on healthcare access impaired the management of chronic conditions. The aim of our study was to examine its effects in context of different antidiabetic therapies on key health related factors in patients with T2DM.

PATIENTS AND METHODS

Materials and Methods: To the study we enrolled 598 adult patients with diagnosed T2DM treated in diabetology outpatient department of the University Clinical Centre (UCC) of the Medical University of Warsaw. Data on body weight, glycated hemoglobin (HbA1c), and creatinine concentration were collected throughout the first COVID-19 pandemic wave and compared to the results obtained before the 4th of March, 2020 (1st confirmed COVID-19 case in Poland).

RESULTS

Results: The HbA1c mean baseline level was 7.15% (±1.39) and increased significantly (7.34% (±1.37), p=0.02) during observation. Importantly, the attendance of patients for HbA1c testing decreased by 57.82% in comparison to the pre-pandemic period. Similarly, creatinine concentrations increased (from 1.27 mg/dl (±0.76) to 1.34 mg/dl (±1.02), (p=0.004)). The increase in creatinine concentration was significantly lower in the group treated with regimens including metformin compared to other regimens. Somewhat surprisingly, the mean body mass remained unchanged.

CONCLUSION

Conclusions: The pandemic period had a significant impact on the tested biochemical parameters. The lesser changes of renal parameters in the group of patients treated with metformin confirms its nephroprotective effect and its value as a first-line treatment in T2DM.

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

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

Population-Wide Screening for Chronic Kidney Disease : A Cost-Effectiveness Analysis

BACKGROUND

Sodium-glucose cotransporter-2 (SGLT2) inhibitors have the potential to alter the natural history of chronic kidney disease (CKD), and they should be included in cost-effectiveness analyses of screening for CKD.

OBJECTIVE

To determine the cost-effectiveness of adding population-wide screening for CKD.

DESIGN

Markov cohort model.

DATA SOURCES

NHANES (National Health and Nutrition Examination Survey), U.S. Centers for Medicare & Medicaid Services data, cohort studies, and randomized clinical trials, including the DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease) trial.

TARGET POPULATION

Adults.

TIME HORIZON

Lifetime.

PERSPECTIVE

Health care sector.

INTERVENTION

Screening for albuminuria with and without adding SGLT2 inhibitors to the current standard of care for CKD.

OUTCOME MEASURES

Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), all discounted at 3% annually.

RESULTS OF BASE-CASE ANALYSIS

One-time CKD screening at age 55 years had an ICER of $86 300 per QALY gained by increasing costs from $249 800 to $259 000 and increasing QALYs from 12.61 to 12.72; this was accompanied by a decrease in the incidence of kidney failure requiring dialysis or kidney transplant of 0.29 percentage points and an increase in life expectancy from 17.29 to 17.45 years. Other options were also cost-effective. During ages 35 to 75 years, screening once prevented dialysis or transplant in 398 000 people and screening every 10 years until age 75 years cost less than $100 000 per QALY gained.

RESULTS OF SENSITIVITY ANALYSIS

When SGLT2 inhibitors were 30% less effective, screening every 10 years during ages 35 to 75 years cost between $145 400 and $182 600 per QALY gained, and price reductions would be required for screening to be cost-effective.

LIMITATION

The efficacy of SGLT2 inhibitors was derived from a single randomized controlled trial.

CONCLUSION

Screening adults for albuminuria to identify CKD could be cost-effective in the United States.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality, Veterans Affairs Office of Academic Affiliations, and National Institute of Diabetes and Digestive and Kidney Diseases.

The Role of Ketone Bodies in Various Animal Models of Kidney Disease

The kidney is a vital organ that carries out significant metabolic functions in our body. Due to the complexity of its role, the kidney is also susceptible to many disease conditions, such as acute kidney injury (AKI) and chronic kidney disease (CKD). Despite the prevalence and our increased understanding of the pathophysiology of both AKI and CKD as well as the transition of AKI to CKD, no well-established therapeutics have been applied clinically to these conditions, rendering an urgent need for a novel potential therapeutic target to be developed. In this article, we reviewed the function of ketone bodies in some common kidney conditions, such as drug-induced nephrotoxicity, ischemia and reperfusion injury, fibrosis development, diabetic kidney disease, kidney aging, hypertension, and CKD progression. All the selected studies reviewed were performed in animal models by primarily utilizing rodents, which also provide invaluable sources for future clinical applications. Ketone bodies have shown significant renal protective properties via attenuation of oxidative stress, increased expression of anti-inflammatory proteins, gene regulation, and a reduction of apoptosis of renal cells. A physiological level of ketone bodies could be achieved by fasting, a ketogenic diet, and an exogenous ketone supplement. Finally, the limitations of the long-term ketogenic diet were also discussed.

One-year mortality after hospitalization for acute heart failure: Predicting factors (PRECIC study subanalysis)

INTRODUCTION AND OBJECTIVES

One-year mortality after hospitalization for heart failure (HF) is high. This study aims to identify predictive factors of one-year mortality.

METHODS

This is a retrospective, single-center and observational study. All patients hospitalized for acute HF for one-year were enrolled.

RESULTS

A total of 429 patients were enrolled, mean age of 79 years. The in-hospital and one-year all-cause mortality rates were 7.9% and 34.3%, respectively. In the univariable analysis, the factors significantly associated with higher one-year mortality risk were: age ≥80 years (odds ratio (OR)=2.05, 95% confidence interval (CI) 1.35-3.11, p=0.001); active cancer (OR=2.93, 95% CI 1.36-6.32, p=0.008); dementia (OR=2.84, 95% CI 1.81-4.47, p<0.001); functional dependency (OR=2.63, 95% CI 1.65-4.19, p<0.001); atrial fibrillation (OR=1.86, 95% CI 1.24-2.80, p=0.004); higher creatinine (OR=2.03, 95% CI 1.29-3.21, p=0.002), urea (OR=2.92, 95% CI 1.95-4.36, p<0.001) and red cell distribution width (RDW; 4thQ OR=5.59, 95% CI 3.03-10.32, p=0.001); and lower hematocrit (OR=0.94, 95% CI 0.91-0.97, p<0.001), hemoglobin (OR=0.83, 95% CI 0.75-0.92, p<0.001) and platelet distribution width (PDW; OR=0.89, 95% CI 0.82-0.97, p=0.005). In the multivariable analysis, the independent predictors of higher one-year mortality risk were: age ≥80 years (OR=2.05, 95% CI 1.21-3.48); active cancer (OR=2.70, 95% CI 1.03-7.01); dementia (OR=2.69, 95% CI 1.53-4.74); higher urea (OR=2.97, 95% CI 1.84-4.80) and RDW (4thQ OR=5.24, 95% CI 2.55-10.76); and lower PDW (OR=0.88, 95% CI 0.80-0.97).

CONCLUSIONS

Active cancer, dementia, and high values for urea and RDW at admission are predictors of one-year mortality in patients hospitalized for HF. These variables are readily available at admission and can support the clinical management of HF patients.

Emerging Role of Sodium-Glucose Co-Transporter 2 Inhibitors for the Treatment of Chronic Kidney Disease

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.

Value of SGLT-2 inhibitors in the treatment of chronic kidney disease : Clinical and practical implications

Chronic kidney disease (CKD) drastically increases the risk for cardiovascular morbidity and mortality and its worldwide prevalence is still rising. Effective treatment slows CKD progression, prevents development of end-stage kidney disease and cardiovascular disease thereby prolonging survival of patients. Recently, several large-scale studies with sodium-glucose cotransport‑2 inhibitors (SGLT-2i) have demonstrated profound nephroprotective and cardioprotective properties in patients with type 2 diabetes mellitus with both CKD and heart failure. Recently, the dapagliflozin and prevention of adverse outcomes in chronic kidney disease (DAPA-CKD) trial demonstrated that the selective SGLT-2i dapagliflozin reduced the hazard ratio for a composite renal and cardiovascular death endpoint in patients with CKD with or without type 2 diabetes. Furthermore, dapagliflozin exerted strong nephroprotection in CKD patients with diverse etiologies like IgA nephropathy. Furthermore, other promising CKD trials such as with empagliflozin are underway. Hence, individualized treatment with SGLT2i represents a promising therapeutic option for patients with both diabetic and non-diabetic CKD. Here we summarize the current knowledge on the treatment with SGLT-2i in CKD patients underscoring a strong rationale for SGLT2 inhibition to be incorporated into standard of care for most CKD patients also with non-diabetic kidney disease. Finally, we aim to translate the current evidence into recommendations for the clinical practice in the management of patients with CKD.

Initiation of sodium-glucose cotransporter-2 inhibitors at lower HbA1c threshold attenuates eGFR decline in type 2 diabetes patients with and without cardiorenal disease: A propensity-matched cohort study

AIM

To examine the association of initiation of sodium-glucose cotransporter-2 inhibitors (SGLT2i) at lower glycemic threshold with decline in estimated-glomerular filtration rate (eGFR).

METHODS

We analyzed a prospective cohort of Chinese patients with type 2 diabetes from Hong Kong. Patients initiating SGLT2i at HbA1c < 7.5 % (lower-HbA1c) versus ≥ 7.5 % (higher-HbA1c) were matched using 1:1 propensity score. We compared annual eGFR changes in the lower-HbA1c and higher-HbA1c groups using linear mixed-effect models. Binary logistic regression was used to explore associations of SGLT2i initiation at lower HbA1c with odds of rapid eGFR decline (>4% per year).

RESULTS

Among 3384 patients with a median follow-up of 1.9 years, the mean age was 60.2 ± 11.5 years and 62.1 % were male. The lower-HbA1c and higher-HbA1c groups had baseline HbA1c (%) of 6.9 ± 0.5 and 9.0 ± 1.3 respectively, with similar pre-index annual eGFR decline. The lower-HbA1c group had a slower post-index annual eGFR decline than the higher-HbA1c group (-0.99 versus -1.63 mL/min/1.73 m², p < 0.001). Overall, the lower-HbA1c group had lower odds of rapid eGFR decline (OR = 0.15, 95 % CI: 0.07-0.29). Greater renoprotection from SGLT2i initiation at lower-HbA1c was observed in those with baseline eGFR < 60 mL/min/1.73 m², albuminuria and/or treatment with renin-angiotensin-system inhibitors or insulin.

CONCLUSIONS

In this real-world study, SGLT2i initiation at HbA1c < 7.5 % was associated with slower eGFR decline especially in high risk patients, supporting the potential renal benefits of SGLT2i initiation at lower glycemic thresholds.

Therapeutic role of mesenchymal stem cells (MSCs) in diabetic kidney disease (DKD)

Findings of preclinical studies and recent phase I/II clinical trials have shown that mesenchymal stem cells (MSCs) play a significant role in the development of diabetic kidney disease (DKD). Thus, MSCs have attracted increasing attention as a novel regenerative therapy for kidney diseases. This review summarizes recent literature on the roles and potential mechanisms, including hyperglycemia regulation, anti-inflammation, anti-fibrosis, pro-angiogenesis, and renal function protection, of MSC-based treatment methods for DKD. This review provides novel insights into understanding the pathogenesis of DKD and guiding the development of biological therapies.

Emerging roles of Sodium-glucose cotransporter 2 inhibitors in Diabetic kidney disease

Diabetic kidney disease (DKD), a severe microvascular complication of diabetes mellitus, is the primary cause of end stage renal disease (ESRD). Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a class of novel anti-diabetic drugs for DKD, which have the potential to prevent renal function from failing. The involved mechanisms have garnered considerable attention. Besides hypoglycemic effect, it seems that various glucose-independent nephroprotective mechanisms also have a role. Among them, improvement in tubuloglomerular feedback is considered as the main reason, followed by reduced intraglomerular pressure and fluid load. In addition, reduced blood pressure, anti-inflammatory effects, nutrient deprivation signaling as well as improved endothelial function are also important. In the future, clinical trials and mechanistic studies might further complement the current knowledge on SGLT2 inhibitors and facilitate to translate these agents to clinical use. Here, we review these mechanisms of SGLT2 inhibitors with an emphasis on kidney protective effects.

Cardiovascular outcomes trials: a paradigm shift in the current management of type 2 diabetes

Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in patients with type 2 diabetes (T2D). Historical concerns about cardiovascular (CV) risks associated with certain glucose-lowering medications gave rise to the introduction of cardiovascular outcomes trials (CVOTs). Initially implemented to help monitor the CV safety of glucose-lowering drugs in patients with T2D, who either had established CVD or were at high risk of CVD, data that emerged from some of these trials started to show benefits. Alongside the anticipated CV safety of many of these agents, evidence for certain sodium-glucose transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have revealed potential cardioprotective effects in patients with T2D who are at high risk of CVD events. Reductions in 3-point major adverse CV events (3P-MACE) and CV death have been noted in some of these CVOTs, with additional benefits including reduced risks of hospitalisation for heart failure, progression of renal disease, and all-cause mortality. These new data are leading to a paradigm shift in the current management of T2D, with international guidelines now prioritising SGLT2 inhibitors and/or GLP-1 RAs in certain patient populations. However, clinicians are faced with a large volume of CVOT data when seeking to use this evidence base to bring opportunities to improve CV, heart failure and renal outcomes, and even reduce mortality, in their patients with T2D. The aim of this review is to provide an in-depth summary of CVOT data-crystallising the key findings, from safety to efficacy-and to offer a practical perspective for physicians. Finally, we discuss the next steps for the post-CVOT era, with ongoing studies that may further transform clinical practice and improve outcomes for people with T2D, heart failure or renal disease.

Update on the management of diabetes in long-term care facilities

The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.

Evaluation of the Clinical Efficacy of the Treatment of Overweight and Obesity in Type 2 Diabetes Mellitus by the Telemedicine Management System Based on the Internet of Things Technology

Objective

To explore the application value of medical intelligent electronic system under the background of Internet of Things in the clinical study of the treatment of overweight/obesity in type 2 diabetes mellitus (T2DM) with empagliflozin combined with liraglutide; 50 overweight and obese adult T2DM patients in our hospital were randomly divided into the combined group and the control group, 25 cases in each group. The control group was treated with liraglutide alone, while the combined group was treated with empagliflozin on the basis of liraglutide. Based on the Internet of Things technology, with diabetes management as the core, the functions of information collection, transmission, and storage of T2DM patients are realized. Doctors pass the diabetes management plan to T2DM patients through the platform, supervise the implementation, and finally compare the clinical efficacy of the two groups.

Results

Compared with before treatment, the body mass index (BMI), fasting blood glucose (FPG), postprandial blood glucose (2hPG), glycosylated hemoglobin (HbAlc), islet beta cell secretion function index (HOMA-β), islet resistance index (HOMA-IR), total cholesterol (TC), and triglyceride (TG) in both groups decreased significantly after treatment. After combined treatment, systolic blood pressure (SBP), diastolic blood pressure (DBP), FPG, 2hPG, HbA1c, and HOMA-IR in the combined group were significantly lower than those in the control group (P < 0.05). Hypoglycemia occurred in both groups, with 2 cases in the control group and 4 cases in the combined group.

Conclusion

The telemedicine management system based on Internet of Things technology can improve patients' self-management ability and provide a new choice for individualized treatment of overweight/obesity T2DM patients. The combination therapy of empagliflozin and liraglutide can effectively reduce blood sugar, weight, blood pressure, blood lipid, and hypoglycemia and effectively improve insulin resistance and secretion function of islet β cells in T2DM patients.

Extra-Glycemic Effects of Anti-Diabetic Medications: Two Birds with One Stone?

The world is suffering from a rapid increase in the number of people with diabetes due to the increased prevalence of obesity and lengthened life span. Since the development of insulin thanks to the efforts of Prof. Banting and Dr. Best in 1922, for which they won the Nobel Prize, remarkable developments in anti-diabetic medications have dramatically lengthened the lifespan of patients with diabetes. However, the control rate of hyperglycemia in patients with diabetes remains unsatisfactory, since glycemic control requires both medication and lifestyle modifications to slow the deterioration of pancreatic beta-cell function and prevent diabetic complications. From the initial "triumvirate" to the "ominous octet," and now the "egregious eleven," the number of organs recognized as being involved in hyperglycemia and diabetes has increased with the development of anti-diabetic medications. Recent unexpected results from outcome trials of anti-diabetic medications have enabled anti-diabetic medications to be indicated for the prevention of chronic kidney disease and heart failure, even in patients without diabetes. In this review, I would like to summarize the extra-glycemic effects of anti-diabetic medications.

The Pathophysiological Basis of Diabetic Kidney Protection by Inhibition of SGLT2 and SGLT1

SGLT2 inhibitors can protect the kidneys of patients with and without type 2 diabetes mellitus and slow the progression towards end-stage kidney disease. Blocking tubular SGLT2 and spilling glucose into the urine, which triggers a metabolic counter-regulation similar to fasting, provides unique benefits, not only as an anti-hyperglycemic strategy. These include a low hypoglycemia risk and a shift from carbohydrate to lipid utilization and mild ketogenesis, thereby reducing body weight and providing an additional energy source. SGLT2 inhibitors counteract hyperreabsorption in the early proximal tubule, which acutely lowers glomerular pressure and filtration and thereby reduces the physical stress on the filtration barrier, the filtration of tubule-toxic compounds, and the oxygen demand for tubular reabsorption. This improves cortical oxygenation, which, together with lesser tubular gluco-toxicity and improved mitochondrial function and autophagy, can reduce pro-inflammatory, pro-senescence, and pro-fibrotic signaling and preserve tubular function and GFR in the long-term. By shifting transport downstream, SGLT2 inhibitors more equally distribute the transport burden along the nephron and may mimic systemic hypoxia to stimulate erythropoiesis, which improves oxygen delivery to the kidney and other organs. SGLT1 inhibition improves glucose homeostasis by delaying intestinal glucose absorption and by increasing the release of gastrointestinal incretins. Combined SGLT1 and SGLT2 inhibition has additive effects on renal glucose excretion and blood glucose control. SGLT1 in the macula densa senses luminal glucose, which affects glomerular hemodynamics and has implications for blood pressure control. More studies are needed to better define the therapeutic potential of SGLT1 inhibition to protect the kidney, alone or in combination with SGLT2 inhibition.

Efficacy and safety of eplerenone treatment for patients with diabetic nephropathy: A meta-analysis

Diabetic nephropathy (DN), which is correlated with an increased risk of cardiovascular disease, significantly elevates the morbidity and mortality of patients with diabetes. Recently, the benefits of mineralocorticoid receptor antagonists in chronic kidney disease (CKD), such as their anti-inflammatory and anti-fibrotic properties, have been discovered. Thus, the present meta-analysis aimed to systematically assess the efficacy and safety of eplerenone treatment in patients with DN. Six electronic databases—PubMed, The Cochrane Library, Embase, Web of Science, CNKI (China National Knowledge Infrastructure), and CBM(Chinese BioMedical Literature Database)—were searched to retrieve randomized controlled trials that assessed eplerenone treatment in patients with DN and were published up to July 31, 2021. Eight randomized controlled trials involving 838 patients were included. Between the eplerenone treatment groups and controls, significant differences were identified in 24-h urine protein levels (mean difference [MD], −19.63 [95% CI, −23.73 to −15.53], P < 0.00001), microalbuminuria (MD, -7.75 [95% CI, -9.75 to -5.75], P < 0.00001), urinary albumin-creatinine ratio (MD, -48.29 [95% CI, -64.45 to -32.14], P < 0.00001), systolic blood pressure (SBP) (MD, -2.49 [95% CI, -4.48 to -0.50], P = 0.01), serum potassium levels (MD, 0.19 [95% CI, 0.13 to 0.24], P < 0.00001), and levels of the renal fibrosis indicator laminin (MD, -8.84 [95% CI, -11.93 to -5.75], P < 0.00001). However, for the effect of estimated glomerular filtration rate (MD, 1.74 [95% CI, -0.87 to 4.35], P = 0.19) and diastolic blood pressure (MD, -0.51 [95% CI, -1.58 to 0.57], P = 0.36), the differences between the two groups were not significant. In addition, no noticeable difference was identified in the adverse events of hyperkalemia and cough between them. These findings suggest that eplerenone exerts beneficial effects on DN by significantly reducing urinary albumin or protein excretion, SBP, and laminin levels, without increasing the incidence of hyperkalemia and other adverse events.

Cardiovascular outcomes associated with prescription of sodium-glucose co-transporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors in patients with diabetes and chronic kidney disease

AIM

To determine the association with cardiovascular (CV) outcomes of sodium-glucose co-transporter-2 (SGLT-2) inhibitors compared with dipeptidyl peptidase-4 (DPP-4) inhibitors in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD).

MATERIALS AND METHODS

We conducted a population-based cohort study of new users of SGLT-2 inhibitors and DPP-4 inhibitors with T2D and CKD using data from Optum Clinformatics DataMart. We assembled three cohorts: T2D/no CKD, T2D/CKD 1-2, and T2D/CKD 3a. The study outcomes were (a) time to first heart failure (HF) hospitalization and (b) time to a composite CV endpoint comprised of non-fatal myocardial infarction (MI) or stroke. After inverse probability of treatment weighting, we used proportional hazards regression to estimate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

New users of SGLT-2 inhibitors versus DPP-4 inhibitors had lower risks of HF hospitalization in the T2D/no CKD (HR, 0.76; 95% CI, 0.70, 0.82) and T2D/CKD 1-2 (HR, 0.63; 95% CI, 0.48, 0.84) cohorts, but no significant association was present in the T2D/CKD 3a cohort. Compared with prescription of DPP-4 inhibitors, SGLT-2 inhibitors were associated with lower risks of non-fatal MI or stroke of 23% (HR, 0.77; 95% CI, 0.70, 0.85) in the T2D/no CKD cohort, but no significant associations were present in the T2D/CKD 1-2 and T2D/CKD 3a cohorts.

CONCLUSIONS

Incident prescription of SGLT-2 inhibitors was associated with lower risks of HF hospitalization but not with non-fatal MI or stroke despite suggesting benefit, relative to prescription of DPP-4 inhibitor across different stages of CKD.

KDOQI US Commentary on the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD

In October 2020, KDIGO (Kidney Disease: Improving Global Outcomes) published its first clinical practice guideline directed specifically to the care of patients with diabetes and chronic kidney disease (CKD). This commentary presents the views of the KDOQI (Kidney Disease Outcomes Quality Initiative) work group for diabetes in CKD, convened by the National Kidney Foundation to provide an independent expert perspective on the new guideline. The KDOQI work group believes that the KDIGO guideline takes a major step forward in clarifying glycemic targets and use of specific antihyperglycemic agents in diabetes and CKD. The purpose of this commentary is to carry forward the conversation regarding optimization of care for patients with diabetes and CKD. Recent developments for prevention of CKD progression and cardiovascular events in people with diabetes and CKD, particularly related to sodium/glucose cotransporter 2 (SGLT2) inhibitors, have filled a longstanding gap in nephrology's approach to the care of persons with diabetes and CKD. The multifaceted benefits of SGLT2 inhibitors have facilitated interactions between nephrology, cardiology, endocrinology, and primary care, underscoring the need for innovative approaches to multidisciplinary care in these patients. We now have more interventions to slow kidney disease progression and prevent or delay kidney failure in patients with diabetes and kidney disease, but methods to streamline their implementation and overcome barriers in access to care, particularly cost, are essential to ensuring all patients may benefit.

Challenges and opportunities in real-world evidence on the renal effects of sodium-glucose cotransporter-2 inhibitors

With increasing population aging and prevalence of type 2 diabetes (T2D) worldwide, prevention of diabetic complications remains a major unmet need. While cardiovascular outcomes of diabetes are improving over time, diabetic kidney disease (DKD) still leads to an exceedingly high rate of end-stage kidney disease (ESKD). A game-changing opportunity is offered by treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors. Randomized controlled trials (RCTs) have indisputably shown that SGLT2 inhibitors reduce the rate of DKD progression, the decline in estimated glomerular filtration rate (eGFR), and the development of ESKD. In parallel, SGLT2 inhibitors improve cardiovascular outcomes, especially the risk of hospitalization for heart failure. Real-world studies (RWSs) have largely confirmed the findings of RCTs in broader populations of subjects with T2D followed under routine care. In the present paper, we review RWSs exploring the renal effects of SGLT2 inhibitors and highlight the most critical challenges that can be encountered in designing and conducting such studies. Channelling bias (confounding by indication), time-lag bias, conditioning on the future, database heterogeneity, linearity of eGFR change over time, and duration of observation are critical issues that may undermine the robustness of RWS findings. We then elaborate on the new opportunities to overcome such limitations by describing the design and objectives of the DARWIN (DApagliflozin Real-World evIdeNce)-Renal study, a new RWS promoted by the Italian Diabetes Society. Fine-tuning of methods for comparative observational research will improve evidence derived from RWSs on the renal effects of SGLT2 inhibitors, aiding the evolving discussion regarding the place of SGLT2 inhibitors in T2D treatment algorithms in different stages of DKD.

SGLT-2 inhibitors as cardio-renal protective agents

Despite remarkable advances in diabetes care, patients with type 2 diabetes are still burdened by higher morbidity and mortality than non-diabetic individuals. Atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease represent the most relevant causes of morbidity and mortality and sustain each other in a vicious circle. Cardiovascular diseases are the main cause of death in patients with chronic kidney disease, and, in turn, chronic kidney disease is a significant contributor to the risk of major cardiovascular events and hospitalization for heart failure. Cardiovascular outcome trials with SGLT-2 inhibitors in type 2 diabetes yielded unprecedented results on prevention of worsening heart failure and renal disease progression and mortality, further confirmed by randomized controlled trials in patients with baseline heart failure and chronic kidney disease, with or without diabetes, and observations from the real-world setting. However, the evidence regarding SGLT-2 inhibitors benefit on atherosclerotic cardiovascular events is conflicting. Hence, SGLT-2 inhibitors represent a remarkably valuable weapon in diabetes management, to be used in the context of a multi-targeted treatment strategy to address the many issues of this multifaceted disease.

Therapeutic Advances in Diabetic Nephropathy

Diabetic kidney disease (DKD) is the most common cause of end-stage kidney disease (ESKD) in the United States. Risk factor modification, such as tight control of blood glucose, management of hypertension and hyperlipidemia, and the use of renin–angiotensin–aldosterone system (RAAS) blockade have been proven to help delay the progression of DKD. In recent years, new therapeutics including sodium-glucose transport protein 2 (SGLT2) inhibitors, endothelin antagonists, glucagon like peptide-1 (GLP-1) agonists, and mineralocorticoid receptor antagonists (MRA), have provided additional treatment options for patients with DKD. This review discusses the various treatment options available to treat patients with diabetic kidney disease.

Understanding the protective effects of SGLT2 inhibitors in type 2 diabetes patients with chronic kidney disease

INTRODUCTION

Sodium-glucose co-transporter type 2 inhibitors (SGLT2is) were developed as glucose-lowering agents for the management of type 2 diabetes (T2D). Unexpectedly, they showed a significant reduction in hospitalization for heart failure and hard renal outcomes in patients with and without T2D. Underlying mechanisms remain a matter of debate.

AREAS COVERED

We summarize the protective renal effects of SGLT2is in patients with cardiovascular disease, chronic kidney disease (CKD, especially with albuminuria) or heart failure; a description of the safety of SGLT2is, with a special focus on the risk/benefit balance in people with stage 3 CKD; a comprehensive discussion of mechanisms that could explain nephro-protection; a reappraisal of the positioning of SGLT2is in recent international guidelines.

EXPERT OPINION

Several mechanisms could contribute to improved renal prognosis with SGLT2is, among which a reduction in intraglomerular pressure by restoring the tubuloglomerular feedback, a diuretic effect that contributes to lower albuminuria and renal decongestion, especially if fluid overload is present, a reduction in renal oxygen consumption, an improvement of heart failure status with less cardiorenal syndrome and a lower risk of acute renal injury. All these effects may be mutually not exclusive, and their respective contribution may differ according to patient characteristics.

The roles of sodium and volume overload on hypertension in chronic kidney disease

Chronic kidney disease (CKD) is associated with increased risk of cardiovascular (CV) events, and the disease burden is rising rapidly. An important contributor to CV events and CKD progression is high blood pressure (BP). The main mechanisms of hypertension in early and advanced CKD are renin-angiotensin system activation and volume overload, respectively. Sodium retention is well known as a factor for high BP in CKD. However, a BP increase in response to total body sodium or volume overload can be limited by neurohormonal modulation. Recent clinical trial data favoring intensive BP lowering in CKD imply that the balance between volume and neurohormonal control could be revisited with respect to the safety and efficacy of strict volume control when using antihypertensive medications. In hemodialysis patients, the role of more liberal use of antihypertensive medications with the concept of functional dry weight for intensive BP control must be studied.

New progress in drugs treatment of diabetic kidney disease

Diabetic kidney disease (DKD) is not only one of the main complications of diabetes, but also the leading cause of the end-stage renal disease (ESRD). The occurrence and development of DKD have always been a serious clinical problem that leads to the increase of morbidity and mortality and the severe damage to the quality of life of human beings. Controlling blood glucose, blood pressure, blood lipids, and improving lifestyle can help slow the progress of DKD. In recent years, with the extensive research on the pathological mechanism and molecular mechanism of DKD, there are more and more new drugs based on this, such as new hypoglycemic drugs sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors with good efficacy in clinical treatment. Besides, there are some newly developed drugs, including protein kinase C (PKC) inhibitors, advanced glycation end product (AGE) inhibitors, aldosterone receptor inhibitors, endothelin receptor (ETR) inhibitors, transforming growth factor-β (TGF-β) inhibitors, Rho kinase (ROCK) inhibitors and so on, which show positive effects in animal or clinical trials and bring hope for the treatment of DKD. In this review, we sort out the progress in the treatment of DKD in recent years, the research status of some emerging drugs, and the potential drugs for the treatment of DKD in the future, hoping to provide some directions for clinical treatment of DKD.

The safety outcomes of sodium-glucose cotransporter 2 inhibitors in patients with different renal function: A systematic review and meta-analysis

AIMS

We aimed to assess whether the safety outcomes exerted by sodium-glucose cotransporter 2 (SGLT2) inhibitors were associated with different renal function at baseline.

DATA SYNTHESIS

We searched randomized controlled trials comparing SGLT2 inhibitors with placebo in participants simultaneously involving the entire range of estimated glomerular filtration rate (eGFR) levels at baseline in one study. According to eGFR, we divided the population into two subgroups with eGFR <60 ml/min/1.73 m² and eGFR≥60 ml/min/1.73 m². Data from the CANVAS program, CREDENCE, EMPA-REG OUTCOME, DECLARE-TIMI 58, DAPA-HF, and EMPA-REG RENAL were included. SGLT2 inhibitors significantly reduced the risk of all serious adverse events (HR 0.91 [95% CI 0.87 to 0.95], p < 0.001) and acute kidney injury (HR 0.74 [95% CI 0.64 to 0.85], p < 0.001). Except for high risk of genital infection, SGLT2 inhibitors did not increase the risk of amputation, fracture, hyperkalemia, hypoglycemia, volume depletion, or urinary tract infection. Further analyses showed that these safety outcomes were similar between subgroups (p-interaction > 0.05). For osmotic diuresis, SGLT2 inhibitors significantly increased the risk by 75% (p = 0.036), and subgroup analyses showed that this effect was completely attributed to the increase in patients with eGFR ≥60 ml/min/1.73 m² (p-interaction<0.001).

CONCLUSION

The indication of no risk of osmotic diuresis in patients with eGFR<60 ml/min/1.73 m² and the consistency of other safety outcomes across different baseline renal function may allow additional individuals to safely use SGLT2 inhibitors.

Therapeutic Targeting of SGLT2: A New Era in the Treatment of Diabetes and Diabetic Kidney Disease

As the prevalence of diabetic kidney disease (DKD) continues to rise, so does the need for a novel therapeutic modality that can control and slow its progression to end-stage renal disease. The advent of sodium-glucose cotransporter-2 (SGLT2) inhibitors has provided a major advancement for the treatment of DKD. However, there still remains insufficient understanding of the mechanism of action and effectiveness of this drug, and as a result, its use has been very limited. Burgeoning evidence suggests that the SGLT2 inhibitors possess renal protective activities that are able to lower glycemic levels, improve blood pressure/hemodynamics, cause bodyweight loss, mitigate oxidative stress, exert anti-inflammatory and anti-fibrotic effects, reduce urinary albumin excretion, lower uric acid levels, diminish the activity of intrarenal renin-angiotensin-aldosterone system, and reduce natriuretic peptide levels. SGLT2 inhibitors have been shown to be safe and beneficial for use in patients with a GFR ≥30mL/min/1.73m², associated with a constellation of signs of metabolic reprogramming, including enhanced ketogenesis, which may be responsible for the correction of metabolic reprogramming that underlies DKD. This article aims to provide a comprehensive overview and better understanding of the SGLT2 inhibitor and its benefits as it pertains to renal pathophysiology. It summarizes our recent understanding on the mechanisms of action of SGLT2 inhibitors, discusses the effects of SGLT2 inhibitors on diabetes and DKD, and presents future research directions and therapeutic potential.

Efficacy of Sodium-Glucose Cotransporter 2 Inhibitors in Patients With Concurrent Type 2 Diabetes Mellitus and Non-Alcoholic Steatohepatitis: A Review of the Evidence

Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disease worldwide, and more than half of individuals diagnosed with type 2 diabetes concurrently present with NAFLD. There is a bidirectional pathological relationship between the two conditions, whereby NAFLD increases the risk of type 2 diabetes, and type 2 diabetes contributes to and accelerates the progression of NAFLD. Furthermore, over 30% of patients with NAFLD progress to non-alcoholic liver steatohepatitis (NASH), which then increases the risk of cirrhosis and hepatocellular carcinoma. Despite its high prevalence and the potential clinical implications, the underlying pathogenesis of NAFLD has yet to be fully elucidated, and there is no consensus regarding standard diagnosis and treatment for either NALFD or NASH. As patients with both NASH and type 2 diabetes have impaired hepatic function owing to chronic inflammation and the resulting structural changes caused by hepatic fat accumulation, they face reduced options for antidiabetic treatment. SGLT-2 inhibitors inhibit glucose reabsorption in the proximal tubule, with increased excretion of glucose in urine and decreased glucose levels in plasma, and their glycemia-lowering effect is insulin-independent. Several other beneficial effects have been reported for SGLT-2 inhibitors, including reduced risks of cardiovascular and renal diseases, improved blood pressure control, body weight reduction, and reductions in liver fat content. Experimental studies in mouse models have suggested that SGLT-2 inhibitors may have beneficial modulatory effects on NAFLD/NASH. Several trials in patients with type 2 diabetes have also suggested that these drugs may be useful in treating both type 2 diabetes and NAFLD or NASH. However, further research is needed to identify the mechanisms by which SGLT-2 inhibitors affect fatty liver and steatohepatitis. In this state-of-the-art review, we explore the literature on the efficacy of SGLT-2 inhibitors in patients with type 2 diabetes and NASH, and present arguments for and against the use of SGLT-2 inhibitors in this patient population.

SGLT2 inhibitors for prevention of cardiorenal events in people with type 2 diabetes without cardiorenal disease: A meta-analysis of large randomized trials and cohort studies

To investigate whether sodium glucose cotransporter 2 inhibitors (SGLT2is) can reduce important cardiorenal endpoints in type 2 diabetic adults without established cardiovascular disease (ECD), in those without heart failure (HF), and in those without chronic kidney disease (CKD). We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and clinicaltrials.gov. Event-driven randomized controlled trials (RCTs) and cohort studies were included. We conducted random-effects meta-analysis, respectively based on RCTs and cohort studies, on eight cardiorenal endpoints in three type 2 diabetic subgroups. Thirteen large studies were included. Meta-analysis of RCTs showed the high quality evidences: compared with placebo, SGLT2is significantly reduced the risk of major adverse cardiovascular events, cardiovascular death or hospitalization for HF, and progression of CKD in type 2 diabetic adults without ECD [HRs (95 % CIs): 0.88 (0.82, 0.94), 0.76 (0.70, 0.82), and 0.59 (0.52, 0.66), respectively; risk differences (95 % CIs): -1.6 (-2.4, -0.8), -2.6 (-3.3, -2.0), and -2.4 (-2.8, -2.0) per 1000 patient-years, respectively], in those without HF [HRs (95 % CIs): 0.89 (0.82, 0.95), 0.74 (0.67, 0.81), and 0.61 (0.55, 0.67), respectively; risk differences (95 % CIs): -1.7 (-2.9, -0.8), -5.8 (-7.3, -4.2), and -2.3 (-2.6, -1.9) per 1000 patient-years, respectively], and in those without CKD [HRs (95 % CIs): 0.88 (0.82, 0.94), 0.77 (0.71, 0.83), and 0.63 (0.57, 0.70), respectively; risk differences (95 % CIs): -2.4 (-3.6, -1.2), -6.1 (-7.6, -4.5), and -2.2 (-2.6, -1.8) per 1000 patient-years, respectively]. Meta-analysis of cohort studies also showed the benefits of SGLT2is on the three composite outcomes in the three diabetic subgroups. SGLT2is also significantly reduced some other cardiorenal endpoints in these diabetic subgroups. SGLT2is can significantly reduce important cardiorenal events in type 2 diabetic adults without ECD, in those without HF, and in those without CKD; which supports SGLT2is used in these diabetic subpopulations to prevent cardiorenal events.

The Off-Target Effects, Electrolyte and Mineral Disorders of SGLT2i

The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a relatively new class of antidiabetic drugs that, in addition to emerging as an effective hypoglycemic treatment, have been shown to improve, in several trials, both renal and cardiovascular outcomes. In consideration of the renal site of action and the associated osmotic diuresis, a negative sodium balance has been postulated during SGLT2i administration. Although it is presumable that sodium and water depletion may contribute to some positive actions of SGLT2i, evidence is far from being conclusive and the real physiologic effects of SGLT2i on sodium remain largely unknown. Indeed, no study has yet investigated how SGLT2i change sodium balance in the long term and especially the pathways through which the natriuretic effect is expressed. Furthermore, recently, several experimental studies have identified different pathways, not directly linked to tubular sodium handling, which could contribute to the renal and cardiovascular benefits associated with SGLT2i. These compounds may also modulate urinary chloride, potassium, magnesium, phosphate, and calcium excretion. Some changes in electrolyte homeostasis are transient, whereas others may persist, suggesting that the administration of SGLT2i may affect mineral and electrolyte balances in exposed subjects. This paper will review the evidence of SGLT2i action on sodium transporters, their off-target effects and their potential role on kidney protection as well as their influence on electrolytes and mineral homeostasis.