1
|
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.
Collapse
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
| |
Collapse
|
2
|
Yokose C, McCormick N, Abhishek A, Dalbeth N, Pascart T, Lioté F, Gaffo A, FitzGerald J, Terkeltaub R, Sise ME, Januzzi JL, Wexler DJ, Choi HK. The clinical benefits of sodium-glucose cotransporter type 2 inhibitors in people with gout. Nat Rev Rheumatol 2024; 20:216-231. [PMID: 38472344 DOI: 10.1038/s41584-024-01092-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/14/2024]
Abstract
Gout is the most common form of inflammatory arthritis worldwide and is characterized by painful recurrent flares of inflammatory arthritis that are associated with a transiently increased risk of adverse cardiovascular events. Furthermore, gout is associated with multiple cardiometabolic-renal comorbidities such as type 2 diabetes, chronic kidney disease and cardiovascular disease. These comorbidities, potentially combined with gout flare-related inflammation, contribute to persistent premature mortality in gout, independently of serum urate concentrations and traditional cardiovascular risk factors. Although better implementation of standard gout care could improve gout outcomes, deliberate efforts to address the cardiovascular risk in patients with gout are likely to be required to reduce mortality. Sodium-glucose cotransporter type 2 (SGLT2) inhibitors are approved for multiple indications owing to their ability to lower the risk of all-cause and cardiovascular death, hospitalizations for heart failure and chronic kidney disease progression, making them an attractive treatment option for gout. These medications have also been shown to lower serum urate concentrations, the causal culprit in gout risk, and are associated with a reduced risk of incident and recurrent gout, potentially owing to their purported anti-inflammatory effects. Thus, SGLT2 inhibition could simultaneously address both the symptoms of gout and its comorbidities.
Collapse
Affiliation(s)
- Chio Yokose
- Rheumatology & Allergy Clinical Epidemiology Research Center (RACER), Mongan Institute, Massachusetts General Hospital, Boston, MA, USA.
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Natalie McCormick
- Rheumatology & Allergy Clinical Epidemiology Research Center (RACER), Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | | | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Tristan Pascart
- Department of Rheumatology, Lille Catholic University, Saint-Philibert Hospital, Lille, France
| | - Frédéric Lioté
- Université Paris Cité, Inserm UMR 1132 Bioscar, centre Viggo Petersen, Hôpital Lariboisière, Paris, France
- Rheumatology Department, Saint-Joseph Paris Hospital, Paris, France
| | - Angelo Gaffo
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham VA Medical Center, Birmingham, AL, USA
| | - John FitzGerald
- Department of Medicine/Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Veterans Health Affairs, Greater Los Angeles, Los Angeles, CA, USA
| | - Robert Terkeltaub
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Meghan E Sise
- Harvard Medical School, Boston, MA, USA
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - James L Januzzi
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Deborah J Wexler
- Harvard Medical School, Boston, MA, USA
- MGH Diabetes Center, Massachusetts General Hospital, Boston, MA, USA
| | - Hyon K Choi
- Rheumatology & Allergy Clinical Epidemiology Research Center (RACER), Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| |
Collapse
|
3
|
Shepard BD, Chau J, Kurtz R, Rosenberg AZ, Sarder P, Border SP, Ginley B, Rodriguez O, Albanese C, Knoer G, Greene A, De Souza AMA, Ranjit S, Levi M, Ecelbarger CM. Nascent shifts in renal cellular metabolism, structure, and function due to chronic empagliflozin in prediabetic mice. Am J Physiol Cell Physiol 2024; 326:C1272-C1290. [PMID: 38602847 DOI: 10.1152/ajpcell.00446.2023] [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: 09/14/2023] [Revised: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 04/13/2024]
Abstract
Sodium-glucose cotransporter, type 2 inhibitors (SGLT2i) are emerging as the gold standard for treatment of type 2 diabetes (T2D) with renal protective benefits independent of glucose lowering. We took a high-level approach to evaluate the effects of the SGLT2i, empagliflozin (EMPA) on renal metabolism and function in a prediabetic model of metabolic syndrome. Male and female 12-wk-old TallyHo (TH) mice, and their closest genetic lean strain (Swiss-Webster, SW) were treated with a high-milk-fat diet (HMFD) plus/minus EMPA (@0.01%) for 12-wk. Kidney weights and glomerular filtration rate were slightly increased by EMPA in the TH mice. Glomerular feature analysis by unsupervised clustering revealed sexually dimorphic clustering, and one unique cluster relating to EMPA. Periodic acid Schiff (PAS) positive areas, reflecting basement membranes and mesangium were slightly reduced by EMPA. Phasor-fluorescent life-time imaging (FLIM) of free-to-protein bound NADH in cortex showed a marginally greater reliance on oxidative phosphorylation with EMPA. Overall, net urine sodium, glucose, and albumin were slightly increased by EMPA. In TH, EMPA reduced the sodium phosphate cotransporter, type 2 (NaPi-2), but increased sodium hydrogen exchanger, type 3 (NHE3). These changes were absent or blunted in SW. EMPA led to changes in urine exosomal microRNA profile including, in females, enhanced levels of miRs 27a-3p, 190a-5p, and 196b-5p. Network analysis revealed "cancer pathways" and "FOXO signaling" as the major regulated pathways. Overall, EMPA treatment to prediabetic mice with limited renal disease resulted in modifications in renal metabolism, structure, and transport, which may preclude and underlie protection against kidney disease with developing T2D.NEW & NOTEWORTHY Renal protection afforded by sodium glucose transporter, type 2 inhibitors (SGLT2i), e.g., empagliflozin (EMPA) involves complex intertwined mechanisms. Using a novel mouse model of obesity with insulin resistance, the TallyHo/Jng (TH) mouse on a high-milk-fat diet (HMFD), we found subtle changes in metabolism including altered regulation of sodium transporters that line the renal tubule. New potential epigenetic determinants of metabolic changes relating to FOXO and cancer signaling pathways were elucidated from an altered urine exosomal microRNA signature.
Collapse
Affiliation(s)
- Blythe D Shepard
- Department of Human Science, Georgetown University, Washington, District of Columbia, United States
| | - Jennifer Chau
- Department of Medicine,Georgetown University, Washington, District of Columbia, United States
| | - Ryan Kurtz
- Department of Human Science, Georgetown University, Washington, District of Columbia, United States
| | - Avi Z Rosenberg
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Pinaki Sarder
- J Crayton Pruitt Department of Biomedical Engineering, University of Florida, Gainesville, Florida, United States
| | - Samuel P Border
- J Crayton Pruitt Department of Biomedical Engineering, University of Florida, Gainesville, Florida, United States
| | - Brandon Ginley
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, United States
- Department of Computational Cell Biology, Anatomy, and Pathology, State University of New York at Buffalo, Buffalo, New York, United States
| | - Olga Rodriguez
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, United States
- Center for Translational Imaging, Georgetown University, Washington, District of Columbia, United States
| | - Chris Albanese
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, United States
- Center for Translational Imaging, Georgetown University, Washington, District of Columbia, United States
- Department of Radiology, Georgetown University, Washington, District of Columbia, United States
| | - Grace Knoer
- Center for Translational Imaging, Georgetown University, Washington, District of Columbia, United States
| | - Aarenee Greene
- Department of Medicine,Georgetown University, Washington, District of Columbia, United States
| | - Aline M A De Souza
- Department of Medicine,Georgetown University, Washington, District of Columbia, United States
| | - Suman Ranjit
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, District of Columbia, United States
- Microscopy & Imaging Shared Resources, Georgetown University, Washington, District of Columbia, United States
| | - Moshe Levi
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, District of Columbia, United States
| | - Carolyn M Ecelbarger
- Department of Medicine,Georgetown University, Washington, District of Columbia, United States
| |
Collapse
|
4
|
Billing AM, Kim YC, Gullaksen S, Schrage B, Raabe J, Hutzfeldt A, Demir F, Kovalenko E, Lassé M, Dugourd A, Fallegger R, Klampe B, Jaegers J, Li Q, Kravtsova O, Crespo-Masip M, Palermo A, Fenton RA, Hoxha E, Blankenberg S, Kirchhof P, Huber TB, Laugesen E, Zeller T, Chrysopoulou M, Saez-Rodriguez J, Magnussen C, Eschenhagen T, Staruschenko A, Siuzdak G, Poulsen PL, Schwab C, Cuello F, Vallon V, Rinschen MM. Metabolic Communication by SGLT2 Inhibition. Circulation 2024; 149:860-884. [PMID: 38152989 PMCID: PMC10922673 DOI: 10.1161/circulationaha.123.065517] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND SGLT2 (sodium-glucose cotransporter 2) inhibitors (SGLT2i) can protect the kidneys and heart, but the underlying mechanism remains poorly understood. METHODS To gain insights on primary effects of SGLT2i that are not confounded by pathophysiologic processes or are secondary to improvement by SGLT2i, we performed an in-depth proteomics, phosphoproteomics, and metabolomics analysis by integrating signatures from multiple metabolic organs and body fluids after 1 week of SGLT2i treatment of nondiabetic as well as diabetic mice with early and uncomplicated hyperglycemia. RESULTS Kidneys of nondiabetic mice reacted most strongly to SGLT2i in terms of proteomic reconfiguration, including evidence for less early proximal tubule glucotoxicity and a broad downregulation of the apical uptake transport machinery (including sodium, glucose, urate, purine bases, and amino acids), supported by mouse and human SGLT2 interactome studies. SGLT2i affected heart and liver signaling, but more reactive organs included the white adipose tissue, showing more lipolysis, and, particularly, the gut microbiome, with a lower relative abundance of bacteria taxa capable of fermenting phenylalanine and tryptophan to cardiovascular uremic toxins, resulting in lower plasma levels of these compounds (including p-cresol sulfate). SGLT2i was detectable in murine stool samples and its addition to human stool microbiota fermentation recapitulated some murine microbiome findings, suggesting direct inhibition of fermentation of aromatic amino acids and tryptophan. In mice lacking SGLT2 and in patients with decompensated heart failure or diabetes, the SGLT2i likewise reduced circulating p-cresol sulfate, and p-cresol impaired contractility and rhythm in human induced pluripotent stem cell-derived engineered heart tissue. CONCLUSIONS SGLT2i reduced microbiome formation of uremic toxins such as p-cresol sulfate and thereby their body exposure and need for renal detoxification, which, combined with direct kidney effects of SGLT2i, including less proximal tubule glucotoxicity and a broad downregulation of apical transporters (including sodium, amino acid, and urate uptake), provides a metabolic foundation for kidney and cardiovascular protection.
Collapse
Affiliation(s)
- Anja M. Billing
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Young Chul Kim
- Departments of Medicine and Pharmacology, University of California San Diego, La Jolla (Y.C.K., M.C.-M., V.V.)
- VA San Diego Healthcare System, CA (Y.C.K., M.C.-M., V.V.)
| | - Søren Gullaksen
- Clinical Medicine (S.G., P.L.P.), Aarhus University, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark (S.G., E.L.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
| | - Janice Raabe
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (J.R., B.K., T.E., F.C.)
| | - Arvid Hutzfeldt
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
| | - Fatih Demir
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Elina Kovalenko
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Moritz Lassé
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
| | - Aurelien Dugourd
- Heidelberg University, Faculty of Medicine, and Heidelberg University Hospital, Institute for Computational Biomedicine, BioQuant, Heidelberg, Germany (A.D., R.F., J.S.-R.)
| | - Robin Fallegger
- Heidelberg University, Faculty of Medicine, and Heidelberg University Hospital, Institute for Computational Biomedicine, BioQuant, Heidelberg, Germany (A.D., R.F., J.S.-R.)
| | - Birgit Klampe
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (J.R., B.K., T.E., F.C.)
| | - Johannes Jaegers
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Qing Li
- Engineering (Q.L., C.S.), Aarhus University, Denmark
| | - Olha Kravtsova
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Maria Crespo-Masip
- Departments of Medicine and Pharmacology, University of California San Diego, La Jolla (Y.C.K., M.C.-M., V.V.)
- VA San Diego Healthcare System, CA (Y.C.K., M.C.-M., V.V.)
| | - Amelia Palermo
- Scripps Research, Center for Metabolomics, San Diego, CA (A.P., G.S., M.M.R.)
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles (A.P.)
| | - Robert A. Fenton
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Elion Hoxha
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (P.K.)
| | - Tobias B. Huber
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
| | - Esben Laugesen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark (S.G., E.L.)
- Diagnostic Centre, Silkeborg Regional Hospital, Denmark (E.L.)
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
| | - Maria Chrysopoulou
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
| | - Julio Saez-Rodriguez
- Heidelberg University, Faculty of Medicine, and Heidelberg University Hospital, Institute for Computational Biomedicine, BioQuant, Heidelberg, Germany (A.D., R.F., J.S.-R.)
| | - Christina Magnussen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (B.S., S.B., P.K., T.Z., C.M.)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
| | - Thomas Eschenhagen
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (J.R., B.K., T.E., F.C.)
| | - Alexander Staruschenko
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa (O.K., A.S.)
| | - Gary Siuzdak
- Scripps Research, Center for Metabolomics, San Diego, CA (A.P., G.S., M.M.R.)
| | - Per L. Poulsen
- Clinical Medicine (S.G., P.L.P.), Aarhus University, Denmark
- Steno Diabetes Center (P.L.P.), Aarhus University, Denmark
| | | | - Friederike Cuello
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (B.S., J.R., S.B., P.K., T.Z., C.M., T.E., F.C.)
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (J.R., B.K., T.E., F.C.)
| | - Volker Vallon
- Departments of Medicine and Pharmacology, University of California San Diego, La Jolla (Y.C.K., M.C.-M., V.V.)
- VA San Diego Healthcare System, CA (Y.C.K., M.C.-M., V.V.)
| | - Markus M. Rinschen
- Departments of Biomedicine (A.M.B., F.D., E.K., J.J., R.A.F., M.C., M.M.R.), Aarhus University, Denmark
- Aarhus Institute of Advanced Studies (M.M.R.), Aarhus University, Denmark
- III Department of Medicine and Hamburg Center for Kidney Health, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (A.H., M.L., E.H., T.B.H., M.M.R.)
- Scripps Research, Center for Metabolomics, San Diego, CA (A.P., G.S., M.M.R.)
| |
Collapse
|
5
|
Sánchez-Briales P, Marques Vidas M, López-Sánchez P, López-Illázquez MV, Martín-Testillano L, Vedat-Ali A, Portolés J. The Uricosuric Effect of SGLT2 Inhibitors Is Maintained in the Long Term in Patients with Chronic Kidney Disease and Type 2 Diabetes Mellitus. J Clin Med 2024; 13:1360. [PMID: 38592682 PMCID: PMC10931679 DOI: 10.3390/jcm13051360] [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: 01/31/2024] [Revised: 02/16/2024] [Accepted: 02/24/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Sodium-glucose co-transporter 2 inhibitors (SGLT2is) increase uric acid excretion. The intensity of uricosuria is linked to glycosuria. (2) Methods: We aim to analyze the effect of SGLT2 inhibitors on urinary fractional excretion (FE) of uric acid and glucose in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) in a single-center retrospective study with patients with T2DM and CKD who started on treatment with SGLT2is. Patients on renal replacement therapy or with glucagon-like peptide-1 (GLP1) analogs were excluded. Subgroup analysis was performed according to the estimated glomerular filtration rate (eGFR), the SGLT2i molecule, the main comorbidities, and concomitant treatment. As a secondary objective, the study analyzed the effect of SGLT2 inhibitors on uricemia levels. (3) Results: Seventy-three patients were analyzed, with a mean follow-up of 1.2 years. Uric acid and glucose FE significantly increased after the initiation of SGLT2is. This increase remained stable during the follow-up without differences among eGFR groups. No significant reduction in uricemia was observed. However, a trend towards a decrease was observed. (4) Conclusion: The use of SGLT2is in patients with CKD and T2DM is associated with an increase in uric acid FE, which maintains stability irrespective of glomerular filtration loss at least during 24 months of follow-up.
Collapse
Affiliation(s)
- Paula Sánchez-Briales
- Nephrology Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (P.S.-B.); (P.L.-S.); (M.V.L.-I.); (L.M.-T.); (A.V.-A.); (J.P.)
| | - María Marques Vidas
- Nephrology Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (P.S.-B.); (P.L.-S.); (M.V.L.-I.); (L.M.-T.); (A.V.-A.); (J.P.)
- Medicine Department, Facultad de Medicina, Universidad Autónoma de Madrid, 28222 Madrid, Spain
| | - Paula López-Sánchez
- Nephrology Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (P.S.-B.); (P.L.-S.); (M.V.L.-I.); (L.M.-T.); (A.V.-A.); (J.P.)
| | - María Victoria López-Illázquez
- Nephrology Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (P.S.-B.); (P.L.-S.); (M.V.L.-I.); (L.M.-T.); (A.V.-A.); (J.P.)
| | - Lucía Martín-Testillano
- Nephrology Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (P.S.-B.); (P.L.-S.); (M.V.L.-I.); (L.M.-T.); (A.V.-A.); (J.P.)
| | - Aylin Vedat-Ali
- Nephrology Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (P.S.-B.); (P.L.-S.); (M.V.L.-I.); (L.M.-T.); (A.V.-A.); (J.P.)
| | - Jose Portolés
- Nephrology Department, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (P.S.-B.); (P.L.-S.); (M.V.L.-I.); (L.M.-T.); (A.V.-A.); (J.P.)
- Medicine Department, Facultad de Medicina, Universidad Autónoma de Madrid, 28222 Madrid, Spain
| |
Collapse
|
6
|
Kishi S, Nagasu H, Kidokoro K, Kashihara N. Oxidative stress and the role of redox signalling in chronic kidney disease. Nat Rev Nephrol 2024; 20:101-119. [PMID: 37857763 DOI: 10.1038/s41581-023-00775-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/21/2023]
Abstract
Chronic kidney disease (CKD) is a major public health concern, underscoring a need to identify pathogenic mechanisms and potential therapeutic targets. Reactive oxygen species (ROS) are derivatives of oxygen molecules that are generated during aerobic metabolism and are involved in a variety of cellular functions that are governed by redox conditions. Low levels of ROS are required for diverse processes, including intracellular signal transduction, metabolism, immune and hypoxic responses, and transcriptional regulation. However, excess ROS can be pathological, and contribute to the development and progression of chronic diseases. Despite evidence linking elevated levels of ROS to CKD development and progression, the use of low-molecular-weight antioxidants to remove ROS has not been successful in preventing or slowing disease progression. More recent advances have enabled evaluation of the molecular interactions between specific ROS and their targets in redox signalling pathways. Such studies may pave the way for the development of sophisticated treatments that allow the selective control of specific ROS-mediated signalling pathways.
Collapse
Affiliation(s)
- Seiji Kishi
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Kengo Kidokoro
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Okayama, Japan.
| |
Collapse
|
7
|
Lai SW, Hwang BF, Liu CS, Liao KF. Comment on "Sodium glucose cotransporter 2 inhibitors and gout risk". Clin Rheumatol 2024; 43:835-836. [PMID: 37821785 DOI: 10.1007/s10067-023-06791-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Shih-Wei Lai
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Bing-Fang Hwang
- Department of Occupational Safety and Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Chiu-Shong Liu
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Kuan-Fu Liao
- College of Medicine, Tzu Chi University, Hualien, Taiwan.
- Division of Hepatogastroenterology, Department of Internal Medicine, Taichung Tzu Chi Hospital, No.66, Sec. 1, Fongsing Road, Tanzi District, Taichung City, 427, Taiwan.
| |
Collapse
|
8
|
Zhang L, Zhang F, Bai Y, Huang L, Zhong Y, Zhang X. Effects of sodium-glucose cotransporter-2 (SGLT-2) inhibitors on serum uric acid levels in patients with chronic kidney disease: a systematic review and network meta-analysis. BMJ Open Diabetes Res Care 2024; 12:e003836. [PMID: 38238025 PMCID: PMC10807021 DOI: 10.1136/bmjdrc-2023-003836] [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: 10/13/2023] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Elevated serum uric acid levels are an independent predictor of occurrence and development of chronic kidney disease (CKD) and are strongly associated with prognosis. Several clinical trials have demonstrated the benefits of sodium-glucose cotransporter-2 (SGLT-2) inhibitors. To evaluate and rank the effects and safety of various SGLT-2 for serum uric acid levels in patients with CKD. We performed a systematic PubMed, Embase, Scopus, and Web of Science search, including studies published before July 1, 2023. Two researchers independently extracted data on study characteristics and outcomes and assessed study quality using the Cochrane Collaboration's risk of bias tool 2. The gemtc package of R software was used to perform network meta-analysis within a Bayesian framework. The primary outcome was serum uric acid levels, and the secondary outcome was adverse events. Effect sizes are reported as standardized mean differences (SMDs), risk ratio (RR), and 95% CI, respectively. The certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria. Eight RCTs (9367 participants) were included in this meta-analysis. The results of the paired meta-analysis showed that SGLT-2 inhibitors significantly reduced serum uric acid levels in patients with CKD compared with the placebo group (SMD -0.22; 95% CI -0.42 to -0.03; GRADE: low). Pooled analysis of any adverse events reported in the included studies showed similar incidence rates in the SGLT-2 inhibitor and placebo groups (RR: 0.99; 95% CI 0.97 to 1.00; p=0.147; GRADE: high). Subgroup analysis showed a statistically significant difference only for tofogliflozin. Further network meta-analysis showed that dapagliflozin 10 mg and ipragliflozin 50 mg may be the most effective in reducing uric acid levels. SGLT-2 inhibitors significantly reduced serum uric acid levels in patients with CKD, and dapagliflozin 10 mg and ipragliflozin 50 mg may be the optimal dosages. SGLT-2 inhibitors hold great promise as an antidiabetic therapeutic option for patients with CKD who have elevated serum uric acid levels. PROSPERO registration number: CRD42023456581.
Collapse
Affiliation(s)
- Linli Zhang
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Xuhui, Shanghai, China
| | - Fan Zhang
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Xuhui, Shanghai, China
| | - Yan Bai
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Xuhui, Shanghai, China
| | - Liuyan Huang
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Xuhui, Shanghai, China
| | - Yifei Zhong
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Xuhui, Shanghai, China
| | - Xianwen Zhang
- Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Xuhui, Shanghai, China
| |
Collapse
|
9
|
Packer M. Hyperuricemia and Gout Reduction by SGLT2 Inhibitors in Diabetes and Heart Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2024; 83:371-381. [PMID: 38199714 DOI: 10.1016/j.jacc.2023.10.030] [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: 08/21/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 01/12/2024]
Abstract
Gout is characterized by increased production of purines (through the pentose phosphate pathway), which is coupled with reduced renal or intestinal excretion of urate. Concurrent upregulation of nutrient surplus signaling (mammalian target of rapamycin and hypoxia-inducible factor-1a) and downregulation of nutrient deprivation signaling (sirtuin-1 and adenosine monophosphate-activated protein kinase) redirects glucose toward anabolic pathways (rather than adenosine triphosphate production), thus promoting heightened oxidative stress and cardiomyocyte and proximal tubular dysfunction, leading to cardiomyopathy and kidney disease. Hyperuricemia is a marker (rather than a driver) of these cellular stresses. By inducing a state of starvation mimicry in a state of nutrient surplus, sodium-glucose cotransporter-2 inhibitors decrease flux through the pentose phosphate pathway (thereby attenuating purine and urate synthesis) while promoting renal urate excretion. These convergent actions exert a meaningful effect to lower serum uric acid by ≈0.6 to 1.5 mg/dL and to reduce the risk of gout by 30% to 50% in large-scale clinical trials.
Collapse
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, Texas, USA; Imperial College, London, United Kingdom.
| |
Collapse
|
10
|
Lai SW. Comment on 'sodium-glucose cotransporter 2 inhibitors and the risk of venous thromboembolism: A population-based cohort study'. Br J Clin Pharmacol 2024; 90:366-367. [PMID: 37935626 DOI: 10.1111/bcp.15947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023] Open
Affiliation(s)
- Shih-Wei Lai
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| |
Collapse
|
11
|
Taylor SI, Cherng HR, Yazdi ZS, Montasser ME, Whitlatch HB, Mitchell BD, Shuldiner AR, Streeten EA, Beitelshees AL. Pharmacogenetics of sodium-glucose co-transporter-2 inhibitors: Validation of a sex-agnostic pharmacodynamic biomarker. Diabetes Obes Metab 2023; 25:3512-3520. [PMID: 37608471 PMCID: PMC10829524 DOI: 10.1111/dom.15246] [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: 06/11/2023] [Revised: 07/21/2023] [Accepted: 07/28/2023] [Indexed: 08/24/2023]
Abstract
AIM To validate pharmacodynamic responses to sodium-glucose co-transporter-2 (SGLT2) inhibitors and test for association with genetic variants in SLC5A4, SLC5A9, and SLC2A9. METHODS Canagliflozin (300 mg), a SGLT2 inhibitor, was administered to 30 healthy volunteers. Several endpoints were measured to assess clinically relevant responses, including drug-induced increases in urinary excretion of glucose, sodium and uric acid. RESULTS This pilot study confirmed that canagliflozin (300 mg) triggered acute changes in mean levels of several biomarkers: fasting plasma glucose (-4.1 mg/dL; P = 6 × 10-5 ), serum creatinine (+0.05 mg/dL; P = 8 × 10-4 ) and serum uric acid (-0.90 mg/dL; P = 5 × 10-10 ). The effects of sex on glucosuria depended upon how data were normalized. Whereas males' responses were ~60% greater when data were normalized to body surface area, males and females exhibited similar responses when glucosuria was expressed as grams of urinary glucose per gram-creatinine. The magnitude of glucosuria was not significantly correlated with fasting plasma glucose, estimated glomerular filtration rate or age in those healthy individuals without diabetes with an estimated glomerular filtration rate of more than 60 mL/min/1.73m2 . CONCLUSIONS Normalizing data relative to creatinine excretion will facilitate including data from males and females in a single analysis. Furthermore, because our ongoing pharmacogenomic study (NCT02891954) is conducted in healthy individuals, this will facilitate detection of genetic associations with limited confounding by other factors such as HbA1c and renal function.
Collapse
Affiliation(s)
- Simeon I. Taylor
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Hua-Ren Cherng
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Zhinous Shahidzadeh Yazdi
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - May E. Montasser
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Hilary B. Whitlatch
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Braxton D. Mitchell
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Alan R. Shuldiner
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Elizabeth A. Streeten
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Amber L. Beitelshees
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| |
Collapse
|
12
|
Terkeltaub R. Emerging Urate-Lowering Drugs and Pharmacologic Treatment Strategies for Gout: A Narrative Review. Drugs 2023; 83:1501-1521. [PMID: 37819612 DOI: 10.1007/s40265-023-01944-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/13/2023]
Abstract
Hyperuricemia with consequent monosodium urate crystal deposition leads to gout, characterized by painful, incapacitating inflammatory arthritis flares that are also associated with increased cardiovascular event and related mortality risk. This narrative review focuses on emerging pharmacologic urate-lowering treatment (ULT) and management strategies in gout. Undertreated, gout can progress to palpable tophi and joint damage. In oral ULT clinical trials, target serum urate of < 6.0 mg/dL can be achieved in ~ 80-90% of subjects, with flare burden reduction by 1-2 years. However, real-world ULT results are far less successful, due to both singular patient nonadherence and prescriber undertreatment, particularly in primary care, where most patients are managed. Multiple dose titrations commonly needed to optimize first-line allopurinol ULT monotherapy, and substantial potential toxicities and other limitations of approved, marketed oral monotherapy ULT drugs, promote hyperuricemia undertreatment. Common gout comorbidities with associated increased mortality (e.g., moderate-severe chronic kidney disease [CKD], type 2 diabetes, hypertension, atherosclerosis, heart failure) heighten ULT treatment complexity and emphasize unmet needs for better and more rapid clinically significant outcomes, including attenuated gout flare burden. The gout drug armamentarium will be expanded by integrating sodium-glucose cotransporter-2 (SGLT2) inhibitors with uricosuric and anti-inflammatory properties as well as clinically indicated antidiabetic, nephroprotective, and/or cardioprotective effects. The broad ULT developmental pipeline is loaded with multiple uricosurics that selectively target uric acid transporter 1 (URAT1). Evolving ULT approaches include administering selected gut anaerobic purine degrading bacteria (PDB), modulating intestinal urate transport, and employing liver-targeted xanthine oxidoreductase mRNA knockdown. Last, emerging measures to decrease the immunogenicity of systemically administered recombinant uricases should simplify treatment regimens and further improve outcomes in managing the most severe gout phenotypes.
Collapse
Affiliation(s)
- Robert Terkeltaub
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA, 92093, USA.
| |
Collapse
|
13
|
Yan W, Wen S, Zhou L. Effect of Intestinal Flora on Hyperuricemia-Induced Chronic Kidney Injury in Type 2 Diabetic Patients and the Therapeutic Mechanism of New Anti-Diabetic Prescription Medications. Diabetes Metab Syndr Obes 2023; 16:3029-3044. [PMID: 37794899 PMCID: PMC10547008 DOI: 10.2147/dmso.s429068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/22/2023] [Indexed: 10/06/2023] Open
Abstract
This article examined the current research on hyperuricemia (HUA) exacerbating diabetic kidney damage and novel anti-diabetic medications for treating these people. Hyperuricemia and type 2 diabetes (T2D), both of which are frequent metabolic disorders, are closely connected. Recent studies have shown that hyperuricemia can increase kidney injury in T2D patients by aggravating insulin resistance, by activating the renin-angiotensin-aldosterone system (RAAS), and by stimulating inflammatory factors, and the diversity, distribution, and metabolites of intestinal flora. Considering this, there are just a few of the research examining the effect of hyperuricemia on diabetic kidney injury via intestinal flora. Through the gut-kidney axis, intestinal flora primarily influences renal function. The primary mechanism is that variations in diversity, distribution, and metabolites of intestinal flora led to alterations in metabolites (such as short-chain fatty acids, Indoxyl sulfate and p-cresol sulfate, Trimethylamine N-oxide TMAO). This article reviewed the research and investigates the association between hyperuricemia and T2D, as well as the influence of hyperuricemia on diabetic kidney injury via intestinal flora. In addition, the current novel antidiabetic drugs are discussed, and their characteristics and mechanisms of action are reviewed. These novel antidiabetic drugs include SGLT2 inhibitors, GLP-1 receptor agonists, DDP-4 inhibitors, glucokinase (GK) enzyme activators (GK agonists), and mineralocorticoid receptor antagonists (MRA). Recent studies suggest that these new anti-diabetic medications may have a therapeutic effect on hyperuricemia-induced kidney impairment in diabetes patients via various mechanisms. Some of these medications may reduce blood uric acid levels, while others may improve kidney function by attenuating the overstimulation of RAAS or by decreasing insulin resistance and inflammation in the kidneys. These novel antidiabetic medicines may have a multifaceted approach to treating hyperuricemia-induced kidney impairment in diabetic patients; nevertheless, additional study is required to establish their efficacy and comprehend their specific mechanisms.
Collapse
Affiliation(s)
- Wei Yan
- Department of Endocrinology, Shanghai Pudong Hospital, n University, Shanghai, 201399, People’s Republic of China
- Department of General Practice, Jinshan Hospital, Fudan University, Shanghai, 201508, People’s Republic of China
| | - Song Wen
- Department of Endocrinology, Shanghai Pudong Hospital, n University, Shanghai, 201399, People’s Republic of China
| | - Ligang Zhou
- Department of Endocrinology, Shanghai Pudong Hospital, n University, Shanghai, 201399, People’s Republic of China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| |
Collapse
|
14
|
Packer M, Butler J, Zeller C, Pocock SJ, Brueckmann M, Ferreira JP, Filippatos G, Usman MS, Zannad F, Anker SD. Blinded Withdrawal of Long-Term Randomized Treatment With Empagliflozin or Placebo in Patients With Heart Failure. Circulation 2023; 148:1011-1022. [PMID: 37621153 PMCID: PMC10516173 DOI: 10.1161/circulationaha.123.065748] [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: 05/26/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND It is not known whether the benefits of sodium-glucose cotransporter 2 inhibitors in heart failure persist after years of therapy. METHODS In the EMPEROR-Reduced (Empagliflozin Outcome Trials in Chronic Heart Failure With Reduced Ejection Fraction) and EMPEROR-Preserved (Empagliflozin Outcome Trials in Chronic Heart Failure With Preserved Ejection Fraction) trials, patients with heart failure were randomly assigned (double-blind) to placebo or empagliflozin 10 mg/day for a median of 16 and 26 months, respectively. At the end of the trials, 6799 patients (placebo 3381, empagliflozin 3418) were prospectively withdrawn from treatment in a blinded manner, and, of these, 3981 patients (placebo 2020, empagliflozin 1961) underwent prespecified in-person assessments after ≈30 days off treatment. RESULTS From 90 days from the start of closeout to the end of double-blind treatment, the annualized risk of cardiovascular death or hospitalization for heart failure was lower in empagliflozin-treated patients than in placebo-treated patients (10.7 [95% CI, 9.0-12.6] versus 13.5 [95% CI, 11.5-15.6] events per 100 patient-years, respectively; hazard ratio 0.76 [95% CI, 0.60-0.96]). When the study drugs were withdrawn for ≈30 days, the annualized risk of cardiovascular death or hospitalization for heart failure increased in patients withdrawn from empagliflozin but not in those withdrawn from placebo (17.0 [95% CI, 12.6-22.1] versus 14.1 [95% CI, 10.1-18.8] events per 100 patient-years for empagliflozin and placebo, respectively). The hazard ratio for the change in risk in the patients withdrawn from empagliflozin was 1.75 (95% CI, 1.20-2.54), P=0.0034, whereas the change in the risk in patients withdrawn from placebo was not significant (hazard ratio 1.12 [95% CI, 0.76-1.66]); time period-by-treatment interaction, P=0.068. After withdrawal, the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score declined by 1.6±0.4 in patients withdrawn from empagliflozin versus placebo (P<0.0001). Furthermore, withdrawal of empagliflozin was accompanied by increases in fasting glucose, body weight, systolic blood pressure, estimated glomerular filtration rate, N-terminal pro-hormone B-type natriuretic peptide, uric acid, and serum bicarbonate and decreases in hemoglobin and hematocrit (all P<0.01). These physiological and laboratory changes were the inverse of the effects of the drug seen at the start of the trials during the initiation of treatment (≈1-3 years earlier) in the same cohort of patients. CONCLUSIONS These observations demonstrate a persistent effect of empagliflozin in patients with heart failure even after years of treatment, which dissipated rapidly after withdrawal of the drug. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT03057977 and NCT03057951.
Collapse
Affiliation(s)
- Milton Packer
- Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, United Kingdom (M.P.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS (J.B.)
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH and Co KG, Biberach, Germany (C.Z.)
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, United Kingdom (S.J.P.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (M.B.)
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Germany (M.B.)
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
- Centre d'Investigations Cliniques Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France (J.P.F., F.Z.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece (G.F.)
| | - Muhammad Shariq Usman
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (M.S.U.)
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France (J.P.F., F.Z.)
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin (S.D.A.)
| |
Collapse
|
15
|
Matthews J, Herat L, Schlaich MP, Matthews V. The Impact of SGLT2 Inhibitors in the Heart and Kidneys Regardless of Diabetes Status. Int J Mol Sci 2023; 24:14243. [PMID: 37762542 PMCID: PMC10532235 DOI: 10.3390/ijms241814243] [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: 08/17/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Chronic Kidney Disease (CKD) and Cardiovascular Disease (CVD) are two devastating diseases that may occur in nondiabetics or individuals with diabetes and, when combined, it is referred to as cardiorenal disease. The impact of cardiorenal disease on society, the economy and the healthcare system is enormous. Although there are numerous therapies for cardiorenal disease, one therapy showing a great deal of promise is sodium-dependent glucose cotransporter 2 (SGLT2) inhibitors. The SGLT family member, SGLT2, is often implicated in the pathogenesis of a range of diseases, and the dysregulation of the activity of SGLT2 markedly effects the transport of glucose and sodium across the luminal membrane of renal cells. Inhibitors of SGLT2 were developed based on the antidiabetic action initiated by inhibiting renal glucose reabsorption, thereby increasing glucosuria. Of great medical significance, large-scale clinical trials utilizing a range of SGLT2 inhibitors have demonstrated both metabolic and biochemical benefits via numerous novel mechanisms, such as sympathoinhibition, which will be discussed in this review. In summary, SGLT2 inhibitors clearly exert cardio-renal protection in people with and without diabetes in both preclinical and clinical settings. This exciting class of inhibitors improve hyperglycemia, high blood pressure, hyperlipidemia and diabetic retinopathy via multiple mechanisms, of which many are yet to be elucidated.
Collapse
Affiliation(s)
- Jennifer Matthews
- Royal Perth Hospital Unit, Dobney Hypertension Centre, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (J.M.); (L.H.)
| | - Lakshini Herat
- Royal Perth Hospital Unit, Dobney Hypertension Centre, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (J.M.); (L.H.)
| | - Markus P. Schlaich
- Royal Perth Hospital Unit, Dobney Hypertension Centre, School of Medicine, University of Western Australia, Crawley, WA 6009, Australia;
- Department of Cardiology and Department of Nephrology, Royal Perth Hospital, Perth, WA 6000, Australia
| | - Vance Matthews
- Royal Perth Hospital Unit, Dobney Hypertension Centre, School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia; (J.M.); (L.H.)
| |
Collapse
|
16
|
Sun S, Chen L, Chen D, Li Y, Liu G, Ma L, Li J, Cao F, Ran X. Prevalence and associated factors of hyperuricemia among Chinese patients with diabetes: a cross-sectional study. Ther Adv Endocrinol Metab 2023; 14:20420188231198620. [PMID: 37719790 PMCID: PMC10501065 DOI: 10.1177/20420188231198620] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Background As a part of metabolic syndrome, hyperuricemia has a higher incidence in patients with diabetes than in the general population owing to various underlying factors. Objectives The objective of the present study was to investigate the prevalence of hyperuricemia among patients with diabetes and identify associated factors. Design A cross-sectional study. Methods Herein, we included patients with diabetes managed at nine healthcare centers in Chenghua District, Chengdu, from February 2021 to November 2021. Clinical data, lifestyle habits, and laboratory data were collected to determine the prevalence and factors associated with hyperuricemia. Results In total, we included 1577 patients with diabetes (males, 50.35%; females, 49.65%). The median serum uric acid level was 337.9 μmol/L, and the prevalence of hyperuricemia in patients with diabetes was 21.24%. The prevalence of hyperuricemia in male patients was significantly higher than in females (29.35% in males versus 13.03% in females, p < 0.001). Male patients with obesity (p = 0.006) or triglyceride (TG) ⩾ 1.7 mmol/L (p < 0.001) had a high risk of developing hyperuricemia, and hyperuricemia was negatively associated with estimated glomerular filtration rate (eGFR) ⩾ 60 mL/min/1.73 m2 (p < 0.001), glycosylated hemoglobin (HbA1c) ⩾ 7% (p < 0.001), fenofibrate (p = 0.010), and sodium-glucose cotransporter 2 (SGLT-2) inhibitors (p = 0.035). Considering females, overweight (p = 0.004), alanine transaminase (ALT) > 40 U/L (p < 0.001), and TG ⩾ 1.7 mmol/L (p = 0.015) showed a significant positive correlation with hyperuricemia, while eGFR ⩾ 60 mL/min/1.73 m2 (p < 0.001) was negatively associated with the risk of hyperuricemia. Conclusion Hyperuricemia is highly prevalent in patients with diabetes, especially in males. In addition to traditionally associated factors, fenofibrate and SGLT-2 inhibitors were also associated with the risk of hyperuricemia. Registration The study protocol was registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn/), and the registration number was ChiCTR 2100042742.
Collapse
Affiliation(s)
- Shiyi Sun
- Department of Endocrinology & Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Innovation Center for Wound Repair, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Lihong Chen
- Department of Endocrinology & Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Innovation Center for Wound Repair, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Dawei Chen
- Department of Endocrinology & Metabolism, West China Hospital, Sichuan University, Chengdu, China
- Innovation Center for Wound Repair, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Li
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, China
| | | | - Lin Ma
- West China School of Nursing, Sichuan University, Chengdu, China
| | - Jun Li
- Wannian Community Health Center in Chenghua District, Chengdu, China
| | - Fangwei Cao
- Baohe Community Health Center in Chenghua District, Chengdu, China
| | - Xingwu Ran
- Department of Endocrinology & Metabolism, West China Hospital, Sichuan University, 37 Guoxue Lane, Wuhou District, Chengdu, Sichuan, China
- Innovation Center for Wound Repair, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu 610041, China
| |
Collapse
|
17
|
Banerjee M, Pal R, Maisnam I, Chowdhury S, Mukhopadhyay S. Serum uric acid lowering and effects of sodium-glucose cotransporter-2 inhibitors on gout: A meta-analysis and meta-regression of randomized controlled trials. Diabetes Obes Metab 2023; 25:2697-2703. [PMID: 37334516 DOI: 10.1111/dom.15157] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/19/2023] [Accepted: 05/20/2023] [Indexed: 06/20/2023]
Abstract
AIMS To pool the effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors on gout and to investigate the association of these effects with baseline serum uric acid (SUA), SUA lowering, and underlying conditions, such as type 2 diabetes mellitus (T2DM)/heart failure (HF). METHODS PubMed, Embase, Web of Science, Cochrane Library and clinical trial registry websites were searched for randomized controlled trials (RCTs) or post hoc analyses (≥1-year duration; PROSPERO:CRD42023418525). The primary outcome was a composite of gouty arthritis/gout flares and commencement of anti-gout drugs (SUA-lowering drugs/colchicine). Hazard ratios (HRs) with 95% confidence interval (CI) were pooled using a generic inverse-variance method with a random-effects model. Mixed-effects model univariate meta-regression analysis was performed. RESULTS Five RCTs involving 29 776 patients (T2DM, n = 23 780) and 1052 gout-related events were identified. Compared to placebo, SGLT2 inhibitor use was significantly associated with reduced risk of composite gout outcomes (HR 0.55, 95% CI 0.45-0.67; I2 = 61%, P < 0.001). Treatment benefits did not differ between trials being conducted exclusively in baseline HF versus those conducted in patients with T2DM (P-interaction = 0.37), but were greater with dapagliflozin 10 mg and canagliflozin 100/300 mg (P < 0.01 for subgroup differences). Sensitivity analysis excluding trials that evaluated the effects of empagliflozin 10/25 mg (HR 0.68, 95% CI 0.57-0.81; I2 = 0%) accentuated the benefits of SGLT2 inhibitors with no between-trial heterogeneity (HR 0.46, 95% CI 0.39-0.55; I2 = 0%). Univariate meta-regression found no impact of baseline SUA, SUA lowering on follow-up, diuretic use, or other variables on their anti-gout effects. CONCLUSION We found that SGLT2 inhibitors significantly reduced the risk of gout in individuals with T2DM/HF. Lack of an association with SUA-lowering effects suggests that metabolic and anti-inflammatory effects of SGLT2 inhibitors may predominantly mediate their anti-gout benefits.
Collapse
Affiliation(s)
- Mainak Banerjee
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Rimesh Pal
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Indira Maisnam
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Subhankar Chowdhury
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Satinath Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| |
Collapse
|
18
|
Schönberger E, Mihaljević V, Steiner K, Šarić S, Kurevija T, Majnarić LT, Bilić Ćurčić I, Canecki-Varžić S. Immunomodulatory Effects of SGLT2 Inhibitors-Targeting Inflammation and Oxidative Stress in Aging. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6671. [PMID: 37681811 PMCID: PMC10487537 DOI: 10.3390/ijerph20176671] [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: 07/14/2023] [Revised: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 09/09/2023]
Abstract
Given that the increase in the aging population has grown into one of the largest public health issues, inflammation and oxidative stress, which are closely associated with the aging process, became a focus of recent research. Sodium-glucose co-transporter 2 (SGLT2) inhibitors, a group of drugs initially developed as oral antidiabetics, have shown many beneficial effects over time, including improvement in renal function and cardioprotective effects. It has been shown that SGLT2 inhibitors, as a drug class, have an immunomodulatory and antioxidative effect, affecting endothelial function as well as metabolic parameters. Therefore, it is not surprising that various studies have investigated the potential mechanisms of action of SGLT2 inhibitors in age-related diseases. The proposed mechanisms by which SGLT2 inhibitors can achieve their anti-inflammatory effects include influence on AMPK/SIRT1/PGC-1α signaling, various cytokines, and the NLRP3 inflammasome. The antioxidative effect is related to their action on mitochondria and their influence on the signaling pathways of transforming growth factor β and nuclear erythroid 2-related factor 2/antioxidant response element. Also, SGLT2 inhibitors achieve their anti-inflammatory and antioxidative effects by affecting metabolic parameters, such as uric acid reduction, stimulation of ketogenesis, reduction of body weight, lipolysis, and epicardial fat tissue. Finally, SGLT2 inhibitors display anti-atherosclerotic effects that modulate inflammatory reactions, potentially resulting in improvement in endothelial function. This narrative review offers a complete and comprehensive overview of the possible pathophysiologic mechanisms of the SGLT2 inhibitors involved in the aging process and development of age-related disease. However, in order to use SGLT2 inhibitor drugs as an anti-aging therapy, further basic and clinical research is needed to elucidate the potential effects and complex mechanisms they have on inflammation processes.
Collapse
Affiliation(s)
- Ema Schönberger
- Department of Endocrinology, University Hospital Osijek, 31000 Osijek, Croatia; (E.S.); (K.S.); (S.C.-V.)
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
| | - Vjera Mihaljević
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia;
| | - Kristina Steiner
- Department of Endocrinology, University Hospital Osijek, 31000 Osijek, Croatia; (E.S.); (K.S.); (S.C.-V.)
| | - Sandra Šarić
- Department for Cardiovascular Disease, University Hospital Osijek, 31000 Osijek, Croatia;
- Department of Internal Medicine and History of Medicine, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Tomislav Kurevija
- Department of Family Medicine, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia; (T.K.); (L.T.M.)
- Health Center Osjecko-Baranjska County, 31000 Osijek, Croatia
| | - Ljiljana Trtica Majnarić
- Department of Family Medicine, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia; (T.K.); (L.T.M.)
| | - Ines Bilić Ćurčić
- Department of Endocrinology, University Hospital Osijek, 31000 Osijek, Croatia; (E.S.); (K.S.); (S.C.-V.)
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Silvija Canecki-Varžić
- Department of Endocrinology, University Hospital Osijek, 31000 Osijek, Croatia; (E.S.); (K.S.); (S.C.-V.)
- Department of Pathophysiology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| |
Collapse
|
19
|
Layton AT, Vallon V. Did you know how SGLT2 inhibitors protect the kidney? Acta Physiol (Oxf) 2023; 238:e14011. [PMID: 37288493 DOI: 10.1111/apha.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Anita T Layton
- Departments of Applied Mathematics and Biology, University of Waterloo, Waterloo, Ontario, Canada
- Cheriton School of Computer Science, School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Volker Vallon
- Departments of Medicine and Pharmacology, University of California, San Diego, La Jolla, California, USA
- San Diego Veterans Affairs Healthcare System, San Diego, California, USA
| |
Collapse
|
20
|
Jong GP, Lin TK, Liao PL, Huang JY, Yang TY, Pan LF. Risk of New-onset Stroke in Patients with Type 2 Diabetes with Chronic Kidney Disease on Sodium-glucose Co-transporter-2 Inhibitor Users. Transl Stroke Res 2023:10.1007/s12975-023-01174-0. [PMID: 37442919 DOI: 10.1007/s12975-023-01174-0] [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: 02/10/2023] [Revised: 07/02/2023] [Accepted: 07/07/2023] [Indexed: 07/15/2023]
Abstract
Clinical studies have investigated the effects of using sodium-glucose co-transporter-2 (SGLT2) inhibitors on the development of new-onset stroke (NOS) in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD), but the findings are inconsistent. This study aimed to examine the association between the use of SGLT2 inhibitors and NOS risk in patients with T2D and CKD. We conducted a nationwide retrospective cohort study using data from the Taiwan Health Insurance Review and Assessment Service database for the years 2004 to 2019. The primary outcome was the risk of incident stroke, which was estimated using hazard ratios (HRs) and 95% confidence intervals (CIs). We used multiple Cox regression modeling to analyze the association between SGLT2 inhibitor use and the risk of stroke in patients with T2D and CKD. In a cohort of 113,710 patients with T2D and CKD who were using SGLT2 inhibitors and 227,420 patients with T2D and CKD who were not using SGLT2 inhibitors, after applying a 1:2 sex- and age-matching strategy, 2,842 and 7,169 NOS events were recorded, respectively. The event rate per 10,000 person-months was 10.60 (95% CI 10.21 to 11.03) for SGLT2 inhibitor users and 13.71 (13.39-14.03) for non-SGLT2 inhibitor users. After adjusting for the index year, sex, age, comorbidities, and concurrent medication, there was a decreased risk of NOS for SGLT2 inhibitor users (adjusted HR 0.80; 95% CI 0.77-0.84) compared with non-SGLT2 inhibitor users. The sensitivity test for the propensity score 1:1-matched analyses showed similar results (adjusted HR 0.80; 95% CI 0.76-0.84). The type of SGLT2 inhibitor subgroup analysis for incident stroke showed consistent results. We concluded that the use of SGLT2 inhibitors in patients with T2D and CKD was associated with significantly low rates of NOS. The significantly low rates of NOS in patients with T2D and CKD were greater among females and less than 50 years patients.
Collapse
Affiliation(s)
- Gwo-Ping Jong
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
- Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Tsung-Kun Lin
- Department of Pharmacy, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan, ROC
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Pei-Lun Liao
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Jing-Yang Huang
- Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Tsung-Yuan Yang
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
- Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Lung-Fa Pan
- Department of Cardiology, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC.
- Department of Medical Imaging and Radiological Science, Central Taiwan University of Science and Technology, Takun, Taichung, Taiwan, ROC.
| |
Collapse
|
21
|
Ameliorative effect of Lacticaseibacillus rhamnosus Fmb14 from Chinese yogurt on hyperuricemia. FOOD SCIENCE AND HUMAN WELLNESS 2023. [DOI: 10.1016/j.fshw.2022.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
22
|
Gohari S, Ghobadi S, Jafari A, Ahangar H, Gohari S, Mahjani M. The effect of dietary approaches to stop hypertension and ketogenic diets intervention on serum uric acid concentration: a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2023; 13:10492. [PMID: 37380733 DOI: 10.1038/s41598-023-37672-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 06/26/2023] [Indexed: 06/30/2023] Open
Abstract
Hyperuricemia as a risk factor for metabolic diseases is proved to be profoundly modified by dietary approaches. This systematic review and meta-analysis of randomized control trials (RCT) was conducted to investigate the effect of two nutritional interventions; dietary approaches to stop hypertension (DASH) diet and ketogenic diet (KD) on serum uric acid (UA) concentrations. Our systematic search was for RCTs in which KD or DASH diet were assigned to adults for at least 2 weeks or more. Until March 2023 in Embase, Web of Science, PubMed, and Scopus databases, 10 eligible RCTs that intervened with DASH diet (n = 4) or KD (n = 6) and had provided laboratory data on serum UA were found. Summary effect was calculated by random-effects model. Results from the meta-analysis of the 4 DASH diet RCTs with a total of 590 participants revealed significant decrease in serum UA after at least 4 weeks of interventions (mean difference (MD) = ‒0.25; 95% CI ‒0.4 to ‒0.1 mg/dL; p < 0.01; I2 = 0%). The pooled meta-analysis of the 6 included RCTs of KD reporting data of 267 participants showed no significant changes in serum UA (MD = 0.26; 95% CI ‒0.47 to 0.98 mg/dL, I2 = 95.32%). However, a non-significant reduction of UA in the subgroup analysis of very low-calorie KD (VLCKD) studies (MD = ‒0.04; 95% CI ‒0.29 to 0.22, I2 = 0%) was obtained. DASH diet has an ameliorating effect on serum UA and may be recommended for hyperuricemia states such as gout. In addition, we have shown that serum UA level following KD remained unchanged. Although, in view of the heterogeneity across the studies, further investigations are needed to determine the effect of KD and VLKD on serum UA concentrations.
Collapse
Affiliation(s)
- Sepehr Gohari
- Student Research Center, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
- Department of Family Medicine, School of Medicine, Alborz University of Medical Sciences, Alborz, Iran
| | - Saeed Ghobadi
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Australia
| | - Alireza Jafari
- Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Hassan Ahangar
- Department of Cardiology, School of Medicine, Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Sheida Gohari
- Department of Systems Science and Industrial Engineering, State University of New York at Binghamton, Binghamton, NY, USA
| | - Mahsa Mahjani
- Department of Family Medicine, School of Medicine, Alborz University of Medical Sciences, Alborz, Iran.
- Endocrine Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Student Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
23
|
Kochanowska A, Rusztyn P, Szczerkowska K, Surma S, Gąsecka A, Jaguszewski MJ, Szarpak Ł, Filipiak KJ. Sodium-Glucose Cotransporter 2 Inhibitors to Decrease the Uric Acid Concentration-A Novel Mechanism of Action. J Cardiovasc Dev Dis 2023; 10:268. [PMID: 37504524 PMCID: PMC10380892 DOI: 10.3390/jcdd10070268] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/29/2023] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are glucose-lowering agents whose positive impact on cardiovascular risk has been described extensively. Not only do they influence lipid profile, blood pressure, atherosclerosis risk, hemoglobin level, and insulin resistance, but they also reduce cardiovascular events, all-cause mortality, and hospitalization rates. Some of these effects may be due to their impact on serum uric acid (SUA) concentration. Findings from nine meta-analyses showed that, indeed, SGLT2is significantly reduce SUA. The data on the drug- and dose-dependency of this effect were inconclusive. Several factors alternating the beneficial effects of SGLT2is on SUA, such as glycated hemoglobin concentration (HbA1c), presence of diabetes, and baseline SUA level, were described. Even though there is a consensus that the lowering of SUA by SGLT2is might be due to the increased urinary excretion rate of uric acid (UEUA) rather than its altered metabolism, the exact mechanism remains unknown. The influence of SGLT2is on SUA may not only be used in gout treatment but may also be of huge importance in explaining the observed pleiotropic effects of SGLT2is.
Collapse
Affiliation(s)
- Anna Kochanowska
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Przemysław Rusztyn
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Karolina Szczerkowska
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Stanisław Surma
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Miłosz J Jaguszewski
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Łukasz Szarpak
- Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy, 03-411 Warsaw, Poland
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Krzysztof J Filipiak
- Institute of Clinical Science, Maria Sklodowska-Curie Medical Academy, 03-411 Warsaw, Poland
- Department of Hypertensiology, Angiology and Internal Medicine, University of Medical Sciences, 61-701 Poznan, Poland
| |
Collapse
|
24
|
Taylor SI, Cherng HR, Yazdi ZS, Montasser ME, Whitlatch HB, Mitchell BD, Shuldiner AR, Streeten EA, Beitelshees AL. Pharmacogenetics of SGLT2 Inhibitors: Validation of a sex-agnostic pharmacodynamic biomarker. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.07.23286875. [PMID: 36945579 PMCID: PMC10029014 DOI: 10.1101/2023.03.07.23286875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Aim SGLT2 inhibitors provide multiple benefits to patients with type 2 diabetes - including improved glycemic control and decreased risks of cardiorenal disease. Because drug responses vary among individuals, we initiated investigations to identify genetic variants associated with the magnitude of drug responses. Methods Canagliflozin (300 mg) was administered to 30 healthy volunteers. Several endpoints were measured to assess clinically relevant responses - including drug-induced increases in urinary excretion of glucose, sodium, and uric acid. Results This pilot study confirmed that canagliflozin (300 mg) triggered acute changes in mean levels of several biomarkers: fasting plasma glucose (-4.1 mg/dL; p=6x10), serum creatinine (+0.05 mg/dL; p=8×10 -4 ), and serum uric acid (-0.90 mg/dL; p=5×10 -10 ). The effects of sex on glucosuria depended upon how data were normalized. Whereas males' responses were ∼60% greater when data were normalized to body surface area, males and females exhibited similar responses when glucosuria was expressed as grams of urinary glucose per gram-creatinine. The magnitude of glucosuria was not significantly correlated with fasting plasma glucose, estimated GFR, or age in these healthy non-diabetic individuals with estimated GFR>60 mL/min/1.73m 2 . Conclusions Normalizing data relative to creatinine excretion will facilitate including data from males and females in a single analysis. Furthermore, because our ongoing pharmacogenomic study ( NCT02891954 ) is conducted in healthy individuals, this will facilitate detection of genetic associations with limited confounding by other factors such as age and renal function. Registration NCT02462421 ( clinicaltrials.gov ). Funding Research grants from the National Institute of Diabetes and Digestive and Kidney Diseases: R21DK105401, R01DK108942, T32DK098107, and P30DK072488.
Collapse
Affiliation(s)
- Simeon I. Taylor
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Hua-Ren Cherng
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Zhinous Shahidzadeh Yazdi
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - May E. Montasser
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Hilary B. Whitlatch
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Braxton D. Mitchell
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Alan R. Shuldiner
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Elizabeth A. Streeten
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| | - Amber L. Beitelshees
- Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 20201, USA
| |
Collapse
|
25
|
Russo E, Bussalino E, Macciò L, Verzola D, Saio M, Esposito P, Leoncini G, Pontremoli R, Viazzi F. Non-Haemodynamic Mechanisms Underlying Hypertension-Associated Damage in Target Kidney Components. Int J Mol Sci 2023; 24:ijms24119422. [PMID: 37298378 DOI: 10.3390/ijms24119422] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/23/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
Arterial hypertension (AH) is a global challenge that greatly impacts cardiovascular morbidity and mortality worldwide. AH is a major risk factor for the development and progression of kidney disease. Several antihypertensive treatment options are already available to counteract the progression of kidney disease. Despite the implementation of the clinical use of renin-angiotensin aldosterone system (RAAS) inhibitors, gliflozins, endothelin receptor antagonists, and their combination, the kidney damage associated with AH is far from being resolved. Fortunately, recent studies on the molecular mechanisms of AH-induced kidney damage have identified novel potential therapeutic targets. Several pathophysiologic pathways have been shown to play a key role in AH-induced kidney damage, including inappropriate tissue activation of the RAAS and immunity system, leading to oxidative stress and inflammation. Moreover, the intracellular effects of increased uric acid and cell phenotype transition showed their link with changes in kidney structure in the early phase of AH. Emerging therapies targeting novel disease mechanisms could provide powerful approaches for hypertensive nephropathy management in the future. In this review, we would like to focus on the interactions of pathways linking the molecular consequences of AH to kidney damage, suggesting how old and new therapies could aim to protect the kidney.
Collapse
Affiliation(s)
- Elisa Russo
- U.O.C. Nefrologia e Dialisi, Ospedale San Luca, 55100 Lucca, Italy
| | - Elisabetta Bussalino
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy
| | - Lucia Macciò
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | | | - Michela Saio
- S.S.D. Nefrologia e Dialisi, Ospedale di Sestri Levante, 16124 Genova, Italy
| | - Pasquale Esposito
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy
| | - Giovanna Leoncini
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy
| | - Roberto Pontremoli
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy
| | - Francesca Viazzi
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy
| |
Collapse
|
26
|
Burnier M. Gout and hyperuricaemia: modifiable cardiovascular risk factors? Front Cardiovasc Med 2023; 10:1190069. [PMID: 37304945 PMCID: PMC10248051 DOI: 10.3389/fcvm.2023.1190069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Gout and hyperuricaemia are two clinical situations associated with an elevated risk of developing cardiovascular (heart failure, myocardial infarction, stroke) and metabolic and renal complications. One reason is probably related to the fact that the prevalence of hyperuricaemia and gout is high in clinical situations, which themselves involve a high cardiovascular risk, such as hypertension, diabetes, chronic kidney disease or obesity. However, recent studies suggest that hyperuricaemia may promote cardiovascular complications independently of other cardiovascular risk factors, by inducing chronic inflammation, oxidative stress, and endothelial dysfunction. The questions that arise today concern primarily the treatment of asymptomatic hyperuricaemia. Should it be treated to decrease the patients' cardiovascular risk and if so, starting from which level and towards which target? There are now several pieces of evidence indicating that this might be useful, but data from large studies are not unanimous. This review will discuss this issue as well as new well-tolerated treatments, such as febuxostat or SGLT2 inhibitors, which lower uric acid levels, prevent gout and lower the risk of cardio-renal events.
Collapse
|
27
|
Iwata Y, Notsu S, Kawamura Y, Mitani W, Tamai S, Morimoto M, Yamato M. The effect of dapagliflozin on uric acid excretion and serum uric acid level in advanced CKD. Sci Rep 2023; 13:4849. [PMID: 36964174 PMCID: PMC10039024 DOI: 10.1038/s41598-023-32072-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/22/2023] [Indexed: 03/26/2023] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) exhibit renoprotective effect in patients with chronic kidney disease (CKD) and reduce serum uric acid (UA) in patients with diabetes mellitus. However, it is not clarified whether SGLT2i reduce serum UA levels in patients with advanced CKD. This study aimed to investigate the impact of SGLT2i on change in serum UA levels in patients with advanced CKD. Data of 121 Japanese patients with CKD who were newly administered 10 mg dapagliflozin in our department between August 2021 and August 2022 were analyzed. Changes in UA and fractional excretion of UA (FEUA) were analyzed using multiple regression analysis. Of 75 patients, 21 (28.0%) patients, 24 (32.0%) patients, 29 (38.7%) patients, and 1 (1.3%) patient were categorized as having CKD stage 3a, 3b, 4, and 5, respectively. The median age was 67 years, and 72.0% were male. 23 (30.7%) of patients had diabetes mellitus. The median estimated glomerular filtration rate, serum UA, and FEUA were 35.7 mL/min/1.73 m2, 6.4 mg/dL, and 6.76%, respectively, at the time of dapagliflozin administration. After administration, serum UA decreased to 5.6 mg/dL and FEUA increased to 9.22%. Dapagliflozin increases FEUA and reduces serum UA levels in patients with advanced CKD.
Collapse
Affiliation(s)
- Yukimasa Iwata
- Department of Nephrology, Sakai City Medical Center, Osaka, Japan
| | - Shoki Notsu
- Department of Nephrology, Sakai City Medical Center, Osaka, Japan
| | - Yushi Kawamura
- Department of Nephrology, Sakai City Medical Center, Osaka, Japan
| | - Waka Mitani
- Department of Nephrology, Sakai City Medical Center, Osaka, Japan
| | - Shinjiro Tamai
- Department of Nephrology, Sakai City Medical Center, Osaka, Japan
| | - Madoka Morimoto
- Department of Nephrology, Sakai City Medical Center, Osaka, Japan
| | - Masafumi Yamato
- Department of Nephrology, Sakai City Medical Center, Osaka, Japan.
| |
Collapse
|
28
|
Afsar B, Afsar RE. Sodium-glucose cotransporter inhibitors and kidney fibrosis: review of the current evidence and related mechanisms. Pharmacol Rep 2023; 75:44-68. [PMID: 36534320 DOI: 10.1007/s43440-022-00442-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/09/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
Sodium-glucose cotransporter inhibitors (SGLT2i) are a new class of anti-diabetic drugs that have beneficial cardiovascular and renal effects. These drugs decrease proximal tubular glucose reabsorption and decrease blood glucose levels as a main anti-diabetic action. Furthermore, SGLT2i decreases glomerular hyperfiltration by a tubuloglomerular feedback mechanism. However, the renal benefits of these agents are independent of glucose-lowering and hemodynamic factors, and SGLT2i also impacts the kidney structure including kidney fibrosis. Renal fibrosis is a common pathway and pathological marker of virtually every type of chronic kidney disease (CKD), and amelioration of renal fibrosis is of utmost importance to reduce the progression of CKD. Recent studies have shown that SGLT2i impact many cellular processes including inflammation, hypoxia, oxidative stress, metabolic functions, and renin-angiotensin system (RAS) which all are related with kidney fibrosis. Indeed, most but not all studies showed that renal fibrosis was ameliorated by SGLT2i through the reduction of inflammation, hypoxia, oxidative stress, and RAS activation. In addition, less known effects on SGLT2i on klotho expression, capillary rarefaction, signal transducer and activator of transcription signaling and peptidylprolyl cis/trans isomerase (Pin1) levels may partly explain the anti-fibrotic effects of SGLT2i in kidneys. It is important to remember that some studies have not shown any beneficial effects of SGLT2i on kidney fibrosis. Given this background, in the current review, we have summarized the studies and pathophysiologic aspects of SGL2 inhibition on renal fibrosis in various CKD models and tried to explain the potential reasons for contrasting findings.
Collapse
Affiliation(s)
- Baris Afsar
- Department of Nephrology, School of Medicine, Suleyman Demirel University, Isparta, Turkey.
| | - Rengin Elsurer Afsar
- Department of Nephrology, School of Medicine, Suleyman Demirel University, Isparta, Turkey
| |
Collapse
|
29
|
Abstract
The sodium-glucose cotransporter 2 (SGLT2) inhibitors have become an integral part of clinical practice guidelines to slow the progression of CKD in patients with and without diabetes mellitus. Although initially developed as antihyperglycemic drugs, their effect on the kidney is multifactorial resulting from profuse glycosuria and natriuresis consequent to their primary site of action. Hemodynamic and metabolic changes ensue that mediate kidney-protective effects, including ( 1 ) decreased workload of proximal tubular cells and prevention of aberrant increases in glycolysis, contributing to a decreased risk of AKI; ( 2 ) lowering of intraglomerular pressure by activating tubular glomerular feedback and reductions in BP and tissue sodium content; ( 3 ) initiation of nutrient-sensing pathways reminiscent of starvation activating ketogenesis, increased autophagy, and restoration of carbon flow through the mitochondria without production of reactive oxygen species; ( 4 ) body weight loss without a reduction in basal metabolic rate due to increases in nonshivering thermogenesis; and ( 5 ) favorable changes in quantity and characteristics of perirenal fat leading to decreased release of adipokines, which adversely affect the glomerular capillary and signal increased sympathetic outflow. Additionally, these drugs stimulate phosphate and magnesium reabsorption and increase uric acid excretion. Familiarity with kidney-specific mechanisms of action, potential changes in kidney function, and/or alterations in electrolytes and volume status, which are induced by these widely prescribed drugs, will facilitate usage in the patients for whom they are indicated.
Collapse
Affiliation(s)
- Biff F. Palmer
- Division of Nephrology, Department of Medicine, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deborah J. Clegg
- Internal Medicine, Texas Tech Health Sciences Center, El Paso, Texas
| |
Collapse
|
30
|
Sinha F, Federlein A, Biesold A, Schwarzfischer M, Krieger K, Schweda F, Tauber P. Empagliflozin increases kidney weight due to increased cell size in the proximal tubule S3 segment and the collecting duct. Front Pharmacol 2023; 14:1118358. [PMID: 37033639 PMCID: PMC10076569 DOI: 10.3389/fphar.2023.1118358] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/14/2023] [Indexed: 04/11/2023] Open
Abstract
The inhibition of renal SGLT2 glucose reabsorption has proven its therapeutic efficacy in chronic kidney disease. SGLT2 inhibitors (SGLTi) have been intensively studied in rodent models to identify the mechanisms of SGLT2i-mediated nephroprotection. So far, the overwhelming effects from clinical trials, could only partially be reproduced in rodent models of renal injury. However, a commonly disregarded observation from these studies, is the increase in kidney weight after SGLT2i administration. Increased kidney mass often relies on tubular growth in response to reabsorption overload during glomerular hyperfiltration. Since SGLT2i suppress hyperfiltration but concomitantly increase renal weight, it seems likely that SGLT2i have a growth promoting effect on the kidney itself, independent of GFR control. This study aimed to investigate the effect of SGLT2i on kidney growth in wildtype animals, to identify enlarged nephron segments and classify the size increase as hypertrophic/hyperplastic growth or cell swelling. SGLT2i empagliflozin increased kidney weight in wildtype mice by 13% compared to controls, while bodyweight and other organs were not affected. The enlarged nephron segments were identified as SGLT2-negative distal segments of proximal tubules and as collecting ducts by histological quantification of tubular cell area. In both segments protein/DNA ratio, a marker for hypertrophic growth, was increased by 6% and 12% respectively, while tubular nuclei number (hyperplasia) was unchanged by empagliflozin. SGLT2-inhibition in early proximal tubules induces a shift of NaCl resorption along the nephron causing compensatory NaCl and H2O reabsorption and presumably cell growth in downstream segments. Consistently, in collecting ducts of empagliflozin-treated mice, mRNA expression of the Na+-channel ENaC and the H2O-channels Aqp-2/Aqp-3 were increased. In addition, the hypoxia marker Hif1α was found increased in intercalated cells of the collecting duct together with evidence for increased proton secretion, as indicated by upregulation of carbonic anhydrases and acidified urine pH in empagliflozin-treated animals. In summary, these data show that SGLT2i induce cell enlargement by hypertrophic growth and possibly cell swelling in healthy kidneys, probably as a result of compensatory glucose, NaCl and H2O hyperreabsorption of SGLT2-negative segments. Particularly affected are the SGLT2-negative proximal tubules (S3) and the collecting duct, areas of low O2 availability.
Collapse
|
31
|
Zhong L, Lin Y, Gong S, Wu X, Liu Y, Chen J, Li Y, Yan F, Su Z, Xie Q. Oxyberberrubine, a novel liver microsomes-mediated secondary metabolite of berberine, alleviates hyperuricemic nephropathy in mice. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 108:154521. [PMID: 36334387 DOI: 10.1016/j.phymed.2022.154521] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/01/2022] [Accepted: 10/21/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Berberrubine (BRB), one of the major metabolites of berberine (BBR), exerts an anti-hyperuricemic effect even superior to BBR. Liver is an important location for drug transformation. Nevertheless, there are few studies on the bioactivities and metabolites of BRB. PURPOSE We investigated whether oxyberberrubine (OBR), a liver metabolite of BRB, exerted urate-lowering and reno-protective effects in hyperuricemic mice. METHODS Liver microsomes were used to incubate BRB for studying its biotransformation. We isolated and identified its new metabolite OBR, and investigated its anti-hyperuricemic and reno-protective effects. In this work, the hyperuricemic mice model was established by receiving potassium oxonate (PO) and hypoxanthine (HX) for 7 consecutive days. 1 h after modeling, different dosages of OBR (5, 10 and 20 mg/kg), BRB (20 mg/kg) or febuxostat (Fex, 5 mg/kg) were given mice by gavage. RESULTS Results showed that OBR possessed potent anti-hyperuricemic and reno-protective effects in hyperuricemic mice. Serum uric acid (UA) level was lowered, and the activities of xanthine oxidase (XOD) as well as adenosine deaminase (ADA) in the liver were suppressed after treatment with OBR. Hepatic expressions of XOD were remarkably decreased at mRNA and protein levels by OBR treatment. In addition, OBR prominently alleviated renal injury, embodied in markedly reduced serum creatinine and blood urea nitrogen (BUN) levels, decreased inflammatory mediators (TNF-α, IL-1β, IL-6 and IL-18) levels, mRNA expression of CYP27B1 and repairment of renal tissues damage. Besides, OBR down-regulated renal expression of urate transporter 1 (URAT1), glucose transporter 9 (GLUT9), NOD-like receptor 3 (NLRP3), apoptosis-associated speck-like protein containing CARD (ASC), and caspase-1 at mRNA and protein levels. CONCLUSIONS In short, our study indicated that OBR possessed superior anti-hyperuricemic and reno-protective effects, at least in part, through the inhibition of XOD, URAT1, GLUT9 and NLRP3 inflammasome signaling pathway in the kidney.
Collapse
Affiliation(s)
- Linjiang Zhong
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Yinsi Lin
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Shiting Gong
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Xiaoyan Wu
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Yuhong Liu
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Jiannan Chen
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Yucui Li
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Fan Yan
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China
| | - Ziren Su
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China.
| | - Qingfeng Xie
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou 510006, PR China; Qi Yu-ru Academic Experience Inheritance Studio, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, PR China.
| |
Collapse
|
32
|
Dong M, Chen H, Wen S, Yuan Y, Yang L, Xu D, Zhou L. The Mechanism of Sodium-Glucose Cotransporter-2 Inhibitors in Reducing Uric Acid in Type 2 Diabetes Mellitus. Diabetes Metab Syndr Obes 2023; 16:437-445. [PMID: 36820272 PMCID: PMC9938669 DOI: 10.2147/dmso.s399343] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/08/2023] [Indexed: 02/16/2023] Open
Abstract
Hyperuricemia is a common comorbidity in patients with type 2 diabetes mellitus (T2DM), as insulin resistance (IR) or hyperinsulinemia is associated with higher serum uric acid (SUA) levels due to decreased uric acid (UA) secretion, and SUA vice versa is an important risk factor that promotes the occurrence and progression of T2DM and its complications. Growing evidence suggests that sodium-glucose cotransporter 2 inhibitors (SGLT-2i), a novel anti-diabetic drug initially developed to treat T2DM, may exert favorable effects in reducing SUA. Currently, one of the possible mechanisms is that SGLT2i increases urinary glucose excretion, probably inhibiting glucose transport 9 (GLUT9)-mediated uric acid reabsorption in the collecting duct, resulting in increased uric acid excretion in exchange for glucose reabsorption. Regardless of this possible mechanism, the underlying comprehensive mechanisms remain poorly elucidated. Therefore, in the present review, a variety of other potential mechanisms will be covered to identify the therapeutic role of SGLT-2i in hyperuricemia.
Collapse
Affiliation(s)
- Meiyuan Dong
- Graduate School of Hebei Medical University, Shijiazhuang, People’s Republic of China
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Huiling Chen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Song Wen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yue Yuan
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Liling Yang
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Dongxiang Xu
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Ligang Zhou
- Graduate School of Hebei Medical University, Shijiazhuang, People’s Republic of China
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, People’s Republic of China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Shanghai Pudong Hospital, Fudan University, Shanghai, People’s Republic of China
- Correspondence: Ligang Zhou, Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, 201399, People’s Republic of China, Tel +8613611927616, Email
| |
Collapse
|
33
|
Wang S, Yuan T, Song S, Duo Y, Zhao T, Gao J, Fu Y, Dong Y, Zhao W. Medium- and Long-Term Effects of Dapagliflozin on Serum Uric Acid Level in Patients with Type 2 Diabetes: A Real-World Study. J Pers Med 2022; 13:jpm13010021. [PMID: 36675682 PMCID: PMC9861887 DOI: 10.3390/jpm13010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
We aimed to explore the medium- and long-term (≥12 weeks) effects of dapagliflozin on serum uric acid (SUA) level in patients with type 2 diabetes mellitus (T2DM) in the real world study and to explore the influencing factors of dapagliflozin on reducing SUA level. This observational, prospective cohort study was based on the real world. There were 77 patients included in this study. They were divided into two groups. Patients in treatment group (n = 38) were treated as dapagliflozin 10 mg/d combined with therapy of routine glucose-lowering drugs (GLDs), and patients in the control group (n = 39) were treated with their routine GLDs. All measurements of physical examinations, blood, and urine samples, including age, sex, weight, height, systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), and SUA, were collected at baseline for all patients in these two groups and repeated after 12, 24, and 48 weeks of therapy. We compared the changes of metabolic indicators including SUA in these two groups to evaluate the effects of dapagliflozin and analyzed its influencing factors. In the dapagliflozin group, mean SUA levels significantly decreased from 334.2 ± 99.1 μmol/L at baseline to 301.9 ± 73.2 μmol/L after 12 weeks therapy (t = 2.378, p = 0.023). There was no significant statistical difference of SUA levels after 24 weeks treatment of dapagliflozin compared with 12-week and 48-week treatment with dapagliflozin (p > 0.05). We found that baseline SUA had a significant impact on the effect of dapagliflozin on reducing SUA (OR 1.014, 95%CI 1.003−1.025, p = 0.014) by logistic regression analysis. Receiver operating characteristic (ROC) curve showed that T2DM patients with SUA level ≥ 314.5 μmol/L had relative accuracy in recognizing the good effects of dapagliflozin on reducing SUA (sensitivity 76.9%, specificity 76.2%). Combination therapy of dapagliflozin with routine blood-glucose-lowering drugs in T2DM patients showed the significant and sustained stable effect of lowering SUA level in this real-world study.
Collapse
|
34
|
Cirillo L, Ravaglia F, Errichiello C, Anders HJ, Romagnani P, Becherucci F. Expectations in children with glomerular diseases from SGLT2 inhibitors. Pediatr Nephrol 2022; 37:2997-3008. [PMID: 35286452 DOI: 10.1007/s00467-022-05504-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 01/10/2023]
Abstract
Chronic kidney disease (CKD) is a global public healthcare concern in the pediatric population, where glomerulopathies represent the second most common cause. Although classification and diagnosis of glomerulopathies still rely mostly on histopathological patterns, patient stratification should complement information supplied by kidney biopsy with clinical data and etiological criteria. Genetic determinants of glomerular injury are particularly relevant in children, with important implications for prognosis and treatment. Targeted therapies addressing the primary cause of the disease are available for a limited number of glomerular diseases. Consequently, in the majority of cases, the treatment of glomerulopathies is actually the treatment of CKD. The efficacy of the currently available strategies is limited, but new prospects evolve. Although the exact mechanisms of action are still under investigation, accumulating data in adults demonstrate the efficacy of sodium-glucose transporter 2 inhibitors (SGLT2i) in slowing the progression of CKD due to diabetic and non-diabetic kidney disease. SGLT2i has proved effective on other comorbidities, such as obesity, glycemic control, and cardiovascular risk that frequently accompany CKD. The use of SGLT2i is not yet approved in children. However, no pathophysiological clues theoretically exclude their application. The hallmark of pediatric CKD is the inevitable imbalance between the metabolic needs of a growing child and the functional capacity of a failing kidney to handle those needs. In this view, developing better strategies to address any modifiable progressor in kidney disease is mandatory, especially considering the long lifespan typical of the pediatric population. By improving the hemodynamic adaptation of the kidney and providing additional beneficial effects on the overall complications of CKD, SGLT2i is a candidate as a potentially innovative drug for the treatment of CKD and glomerular diseases in children.
Collapse
Affiliation(s)
- Luigi Cirillo
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | | | | | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Paola Romagnani
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | | |
Collapse
|
35
|
Kim GH, Jun JB. Altered Serum Uric Acid Levels in Kidney Disorders. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111891. [PMID: 36431026 PMCID: PMC9692609 DOI: 10.3390/life12111891] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/07/2022] [Accepted: 11/13/2022] [Indexed: 11/17/2022]
Abstract
Serum uric acid levels are altered by kidney disorders because the kidneys play a dominant role in uric acid excretion. Here, major kidney disorders which accompany hyperuricemia or hypouricemia, including their pathophysiology, are discussed. Chronic kidney disease (CKD) and hyperuricemia are frequently associated, but recent clinical trials have not supported the pathogenic roles of hyperuricemia in CKD incidence and progression. Diabetes mellitus (DM) is often associated with hyperuricemia, and hyperuricemia may be associated with an increased risk of diabetic kidney disease in patients with type 2 DM. Sodium-glucose cotransporter 2 inhibitors have a uricosuric effect and can relieve hyperuricemia in DM. Autosomal dominant tubulointerstitial kidney disease (ADTKD) is an important hereditary kidney disease, mainly caused by mutations of uromodulin (UMOD) or mucin-1 (MUC-1). Hyperuricemia and gout are the major clinical manifestations of ADTKD-UMOD and ADTKD-MUC1. Renal hypouricemia is caused by URAT1 or GLUT9 loss-of-function mutations and renders patients susceptible to exercise-induced acute kidney injury, probably because of excessive urinary uric acid excretion. Hypouricemia derived from renal uric acid wasting is a component of Fanconi syndrome, which can be hereditary or acquired. During treatment for human immunodeficiency virus, hepatitis B or cytomegalovirus, tenofovir, adefovir, and cidofovir may cause drug-induced renal Fanconi syndrome. In coronavirus disease 2019, hypouricemia due to proximal tubular injury is related to disease severity, including respiratory failure. Finally, serum uric acid and the fractional excretion of uric acid are indicative of plasma volume status; hyperuricemia caused by the enhanced uric acid reabsorption can be induced by volume depletion, and hypouricemia caused by an increased fractional excretion of uric acid is the characteristic finding in syndromes of inappropriate anti-diuresis, cerebral/renal salt wasting, and thiazide-induced hyponatremia. Molecular mechanisms by which uric acid transport is dysregulated in volume or water balance disorders need to be investigated.
Collapse
Affiliation(s)
- Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
- Correspondence: ; Tel.: +82-2-2290-8318
| | - Jae-Bum Jun
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul 04763, Republic of Korea
| |
Collapse
|
36
|
Patel R, Fu Y, Khang S, Benardeau AM, Thomson SC, Vallon V. Responses in Blood Pressure and Kidney Function to Soluble Guanylyl Cyclase Stimulation or Activation in Normal and Diabetic Rats. Nephron Clin Pract 2022; 147:281-300. [PMID: 36265461 PMCID: PMC10115913 DOI: 10.1159/000526934] [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: 03/04/2022] [Accepted: 08/22/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction: Agonists of soluble guanylate cyclase (sGC) are being developed as treatment for cardiovascular disease. Most effects of nitric oxide (NO) on glomerular and tubular function are mediated through sGC but whether sGC agonists mimic these effects is unknown. Methods: Renal clearance and micropuncture studies were performed in Wistar-Froemter rats (WF), with or without streptozotocin diabetes (STZ-WF), and in Goto-Kakizaki rats (GK) with mild type-2 diabetes to test for acute effects of the sGC “stimulator” BAY 41-2272, which synergizes with endogenous NO, and the “activator” runcaciguat, which generates cGMP independent of NO. Results: Both sGC agonists reduced arterial blood pressure (MAP). For MAP reductions <10% the drugs increased GFR in WF and STZ-WF but not in GK. Larger MAP reductions outweighed this effect and GFR declined, with better preserved GFR in STZ-WF. Changes in GFR could not be accounted for by changes in RBF, suggesting parallel changes in ultrafiltration pressure and/or ultrafiltration coefficient. The doses chosen for micropuncture in WF and GK reduced MAP by 2–10% and the net effect on single nephron GFR and ultrafiltration pressure was neutral. Effects of the drugs on tubular reabsorption were dominated by declining MAP and no natriuretic effect observed at any dose. Discussion/Conclusion: sGC agonists impact kidney function directly and because they reduce MAP. The direct tendency to increase GFR is most apparent for MAP reductions <10%. The direct effect is otherwise subtle and overridden when MAP declines more. Effects of sGC agonists on tubular reabsorption are dominated by effects on MAP.
Collapse
Affiliation(s)
- Rohit Patel
- Department of Medicine, University of California San Diego, La Jolla, USA & VA San Diego Healthcare System, San Diego, USA
| | - Yiling Fu
- Department of Medicine, University of California San Diego, La Jolla, USA & VA San Diego Healthcare System, San Diego, USA
| | - Ser Khang
- Department of Medicine, University of California San Diego, La Jolla, USA & VA San Diego Healthcare System, San Diego, USA
| | | | - Scott C. Thomson
- Department of Medicine, University of California San Diego, La Jolla, USA & VA San Diego Healthcare System, San Diego, USA
| | - Volker Vallon
- Department of Medicine, University of California San Diego, La Jolla, USA & VA San Diego Healthcare System, San Diego, USA
- Department of Pharmacology, University of California San Diego, La Jolla, USA
| |
Collapse
|
37
|
Abstract
SGLT2 inhibitors can protect the kidneys of patients with and without type 2 diabetes from failing. This includes blood glucose dependent and independent mechanisms. SGLT2 inhibitors lower glomerular pressure and filtration, thereby reducing the physical stress on the filtration barrier and the oxygen demand for tubular reabsorption. This improves cortical oxygenation, which, together with lesser tubular glucotoxicity and improved mitochondrial function and autophagy, can reduce proinflammatory and profibrotic signaling and preserve tubular function and GFR in long term. By shifting transport downstream, SGLT2 inhibitors may mimic systemic hypoxia and stimulate erythropoiesis, which improves oxygen delivery to the kidney and other organs.
Collapse
Affiliation(s)
- Volker Vallon
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA; Department of Pharmacology, University of California San Diego, La Jolla, CA, USA; VA San Diego Healthcare System, 3350 La Jolla Village Drive (9151), San Diego, CA 92161, USA.
| |
Collapse
|
38
|
Zhao SS, Rajasundaram S, Karhunen V, Alam U, Gill D. Sodium-glucose cotransporter 1 inhibition and gout: Mendelian randomisation study. Semin Arthritis Rheum 2022; 56:152058. [PMID: 35839537 DOI: 10.1016/j.semarthrit.2022.152058] [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: 05/06/2022] [Revised: 06/03/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce serum urate, but their efficacy depends on renal function which is often impaired in people with gout. SGLT1 is primarily expressed in the small intestine and its inhibition may be a more suitable therapeutic target. We aimed to investigate the association of genetically proxied SGLT1i with gout risk, serum urate levels and cardiovascular safety using Mendelian randomisation (MR). METHODS Leveraging data from a genome-wide association study of 344,182 individuals in the UK Biobank, we identified a missense variant in the SLC5A1 gene that associated with glycated haemoglobin (HbA1c) to proxy SGLT1i. Outcome genetic data comprised 13,179 gout cases and 750,634 controls, 457,690 individuals for serum urate levels, and up to 977,323 individuals for cardiovascular safety outcomes. We applied the Wald ratio method and investigated potential genetic confounding using colocalization. RESULTS The rs17683430 missense variant was selected to instrument SGLT1i. Genetically proxied SGLT1i was associated with 75% reduction in gout risk (OR 0.25; 95%CI 0.06, 0.99; p = 0.048) and 32.0 μmol/L reduction in serum urate (95%CI -56.7, -7.3; p = 0.01), per 6.7 mmol/mol reduction in HbA1c. SGLT1i was associated with increased levels of low-density lipoprotein cholesterol (0.37 mmol/L; 95%CI 0.17, 0.56; p = 0.0002) but not risk of coronary heart disease, stroke, or chronic kidney disease. Colocalization did not suggest that results are attributable to genetic confounding. CONCLUSION SGLT1 inhibition may represent a novel therapeutic option for preventing gout in people with or without comorbid diabetes. Randomised trials are needed to formally investigate efficacy and safety.
Collapse
Affiliation(s)
- Sizheng Steven Zhao
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, School of Biological Sciences, Faculty of Biological Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK.
| | - Skanda Rajasundaram
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK; Faculty of Medicine, Imperial College London, London, UK
| | - Ville Karhunen
- Research Unit of Mathematical Sciences, University of Oulu, Oulu, Finland; Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Uazman Alam
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK; Department of Diabetes & Endocrinology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK; Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester, UK
| | - Dipender Gill
- Centre of Excellence in Genetics, Novo Nordisk Research Centre Oxford, Oxford, UK; Department of Epidemiology and Biostatistics, Imperial College London, London, UK; Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| |
Collapse
|
39
|
Lu YP, Zhang ZY, Wu HW, Fang LJ, Hu B, Tang C, Zhang YQ, Yin L, Tang DE, Zheng ZH, Zhu T, Dai Y. SGLT2 inhibitors improve kidney function and morphology by regulating renal metabolic reprogramming in mice with diabetic kidney disease. J Transl Med 2022; 20:420. [PMID: 36104729 PMCID: PMC9476562 DOI: 10.1186/s12967-022-03629-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease (ESRD) worldwide. SGLT2 inhibitors are clinically effective in halting DKD progression. However, the underlying mechanisms remain unclear. The serum and kidneys of mice with DKD were analyzed using liquid chromatography with tandem mass spectrometry (LC–MS/MS)-based metabolomic and proteomic analyses. Three groups were established: placebo-treated littermate db/m mice, placebo-treated db/db mice and EMPA-treated db/db mice. Empagliflozin (EMPA) and placebo (10 mg/kg/d) were administered for 12 weeks. EMPA treatment decreased Cys-C and urinary albumin excretion compared with placebo by 78.60% and 57.12%, respectively (p < 0.001 in all cases). Renal glomerular area, interstitial fibrosis and glomerulosclerosis were decreased by 16.47%, 68.50% and 62.82%, respectively (p < 0.05 in all cases). Multi-omic analysis revealed that EMPA treatment altered the protein and metabolic profiles in the db/db group, including 32 renal proteins, 51 serum proteins, 94 renal metabolites and 37 serum metabolites. Five EMPA-related metabolic pathways were identified by integrating proteomic and metabolomic analyses, which are involved in renal purine metabolism; pyrimidine metabolism; tryptophan metabolism; nicotinate and nicotinamide metabolism, and glycine, serine and threonine metabolism in serum. In conclusion, this study demonstrated metabolic reprogramming in mice with DKD. EMPA treatment improved kidney function and morphology by regulating metabolic reprogramming, including regulation of renal reductive stress, alleviation of mitochondrial dysfunction and reduction in renal oxidative stress reaction.
Collapse
|
40
|
Zhou J, Liu X, Chou OHI, Li L, Lee S, Wong WT, Zhang Q, Chang C, Liu T, Tse G, Jing F, Cheung BMY. Lower risk of gout in sodium glucose cotransporter 2 (SGLT2) inhibitors versus dipeptidyl peptidase-4 (DPP4) inhibitors in type-2 diabetes. Rheumatology (Oxford) 2022; 62:1501-1510. [PMID: 36066415 DOI: 10.1093/rheumatology/keac509] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/25/2022] [Accepted: 08/13/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The effects of sodium-glucose cotransporter 2 inhibitors (SGLT2I) vs dipeptidyl peptidase-4 inhibitors (DPP4I) on the risk of new-onset gout remains unknown. This study aims to compare the effects of SGLT2I against DPP4I on gout risks. METHODS This was a retrospective population-based cohort study of patients with type-2 diabetes mellitus treated with SGLT2I or DPP4I between January 1st, 2015 and December 31st, 2020 in Hong Kong. The study outcomes are new-onset gout and all-cause mortality. Propensity score matching (1:1 ratio) between SGLT2I and DPP4I was performed. Univariable and multivariable Cox regression analysis models were conducted. Competing risks models and multiple approaches based on the propensity score were applied. RESULTS This study included 43201 patients (median age: 63.23 years old [Interquantile range, IQR]: 55.21-71.95, 53.74% males; SGLTI group: n = 16144; DPP4I group: n = 27057) with a median follow-up of 5.59 years (IQR: 5.27-5.81 years) since initial drug exposure. The incidence rate of developing gout (Incidence rate [IR]: 2.5; 95% CI: 2.2-2.9) among SGLT2I users was significantly lower than DPP4I users (IR: 5.2; 95% CI: 4.8-5.8). SGLT2 was associated with 51% lower risks of gout (HR: 0.49; 95% CI: 0.42-0.58; P-value < 0.0001) and 51% lower risks of all-cause mortality (HR: 0.49; 95% CI: 0.42-0.58; P-value < 0.0001) after adjusting for significant demographics, past comorbidities, medications, and laboratory results. The results remained consistent on competing risk and other propensity score approaches. CONCLUSIONS SGLT2I use was associated with lower risks of new gout diagnosis compared with DPP4I use.
Collapse
Affiliation(s)
- Jiandong Zhou
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Diabetes Research Unit, Cardiovascular Analytics Group, Hong Kong, China, UK Collaboration
| | - Xuejin Liu
- School of Educational Science, Kaili University, Kaili, Guizhou, China
| | - Oscar Hou-In Chou
- School of Educational Science, Kaili University, Kaili, Guizhou, China.,Division of Clinical Pharmacology, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Lifang Li
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Sharen Lee
- Diabetes Research Unit, Cardiovascular Analytics Group, Hong Kong, China, UK Collaboration
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, China
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Carlin Chang
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Gary Tse
- Diabetes Research Unit, Cardiovascular Analytics Group, Hong Kong, China, UK Collaboration.,Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, China.,Kent and Medway Medical School, Canterbury, United Kingdom
| | - Fengshi Jing
- Institute for Artificial Intelligence, Guangdong Second Provincial General Hospital, Guangzhou, China.,The University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Bernard Man Yung Cheung
- Division of Clinical Pharmacology, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| |
Collapse
|
41
|
Park G, Choi B, Kang S, Kim B, Chang MJ. Sodium-Glucose Cotransporter-2 Inhibitors Could Help Delay Renal Impairment in Patients with Type 2 Diabetes: A Real-World Clinical Setting. J Clin Med 2022; 11:jcm11185259. [PMID: 36142907 PMCID: PMC9502124 DOI: 10.3390/jcm11185259] [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: 07/29/2022] [Revised: 08/28/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
This study compared the renoprotective effects of sodium−glucose cotransporter-2 (SGLT2) inhibitors and dipeptidyl peptidase-4 (DPP-4) inhibitors in patients with type 2 diabetes mellitus (T2DM). We performed a retrospective cohort study using electronic medical records of patients with T2DM. The primary outcome was the first occurrence of an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 after the index date. We analyzed changes in repeatedly measured laboratory data, such as eGFR and serum uric acid (SUA). We included 2396 patients (1198 patients in each group) in the present study. The rate of renal events was significantly lower in the SGLT2 inhibitors group than that in the DPP-4 inhibitors group (hazard ratio, 0.46; 95% CI, 0.29 to 0.72; p = 0.0007). The annual mean change in the eGFR was significantly smaller in the SGLT2 inhibitors group than that in the DPP-4 inhibitors group, with a between-group difference of 0.86 ± 0.18 mL/min/1.73 m2 per year (95% CI, 0.49 to 1.23; p < 0.0001). Moreover, the mean change in SUA was lower in the SGLT2 inhibitors group. Considering the lower incidence of renal impairment, the slower decline in eGFR, and reduced SUA, SGLT2 inhibitors could help delay renal impairment in patients with T2DM.
Collapse
Affiliation(s)
- Gyunam Park
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
| | - Byungha Choi
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon 21983, Korea
| | - Soyoung Kang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
| | - Bomin Kim
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
| | - Min Jung Chang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon 21983, Korea
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
- Correspondence: ; Tel.: +82-32-749-4517; Fax: +82-32-749-4105
| |
Collapse
|
42
|
Frent I, Leucuta D, Bucsa C, Farcas A, Casoinic F, Mogosan C. A Description of Acute Renal Failure and Nephrolithiasis Associated With Sodium–Glucose Co-Transporter 2 Inhibitor Use: A VigiBase Study. Front Pharmacol 2022; 13:925805. [PMID: 36003521 PMCID: PMC9393368 DOI: 10.3389/fphar.2022.925805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background: The Food and Drug Administration issued a warning on the risk of acute kidney injury and a signal of nephrolithiasis for patients using sodium–glucose co-transporter 2 inhibitors (SGLT2i). We performed a descriptive analysis on acute renal failure (ARF) and nephrolithiasis cases reported to SGLT2i in the VigiBase®, in the scope of characterizing the patients and reactions and to report on the disproportionality analysis. Methods: We analyzed all ARF and nephrolithiasis reports for SGLT2i in VigiBase from inception to September 2021. ARF cases were defined as reports containing at least one of the preferred terms (PTs) included in the ARF narrow Medical Dictionary for Regulatory Activities Standardised Queries (MedDRA SMQ). SGLT2i exposure was considered for reports with at least one gliflozin as a suspected/interacting drug. We characterized the patients, reporters, and reactions, and we present the proportional reporting ratio (PRR). Results: Of 27,370,413 total reports in VigiBase, we found 3,972 ARF reactions to gliflozins as suspected/interacting drugs in 3,751 patients and 231 nephrolithiasis reactions in 227 patients. Most cases were reported from American regions (3057; 81.49%), for patients of age group 45–64 years (1590; 59%). About 30% (1156) of the ARF reports were registered in 2018, most from spontaneous reporting, and from consumers followed by healthcare professionals (2,235; 61% and 1440; 38%, respectively). Canagliflozin was the most involved gliflozin in the ARF and nephrolithiasis cases (2,640; 67% and 109; 47%, respectively). The great majority of ARF and nephrolithiasis reports were serious (3,761; 95% and 182; 79%, respectively). Of the total ARF cases reported, 51 had fatal outcome, while 152 had not recovered/not resolved outcome. No fatal outcome was reported for nephrolithiasis. Disproportionality analysis in full database showed a PRR of 4.68 (95% CI 4.53–4.83) for all gliflozins–ARF and a PRR of 3.44 (95% CI 3.00–3.95) for all gliflozins–nephrolithiasis. Conclusion: Most of ARF reports associated with gliflozins were serious, with an important number of cases with fatal outcome. A drug safety signal was found between ARF narrow SMQ and gliflozins. Also, gliflozins were associated with an increase in the proportion of nephrolithiasis reports compared to other medications.
Collapse
Affiliation(s)
- Ioana Frent
- Department of Pharmacology, Physiology and Physiopathology, Faculty of Pharmacy, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Daniel Leucuta
- Department of Medical Informatics and Biostatistics, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
- *Correspondence: Daniel Leucuta,
| | - Camelia Bucsa
- Pharmacovigilance Research Center, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andreea Farcas
- Pharmacovigilance Research Center, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Florin Casoinic
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cristina Mogosan
- Department of Pharmacology, Physiology and Physiopathology, Faculty of Pharmacy, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| |
Collapse
|
43
|
Balasubramanian P, Wanner C, Ferreira JP, Ofstad AP, Elsaesser A, Zinman B, Inzucchi SE. Empagliflozin and Decreased Risk of Nephrolithiasis: A Potential New Role for SGLT2 Inhibition? J Clin Endocrinol Metab 2022; 107:e3003-e3007. [PMID: 35290464 PMCID: PMC9202688 DOI: 10.1210/clinem/dgac154] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Diabetes mellitus is a risk factor for nephrolithiasis. A recent observational study found that in patients with type 2 diabetes (T2D), SGLT2 inhibitor use was associated with a 49% lower risk of nephrolithiasis compared with GLP-1 receptor agonists. OBJECTIVE We examined the association between nephrolithiasis and the SGLT2 inhibitor empagliflozin, using existing data from randomized clinical trials. METHODS We pooled data from 15 081 T2D patients randomized to empagliflozin (n = 10 177) or placebo (n = 4904) from 20 phase I-IV trials, including the large cardiovascular outcome trial, EMPA-REG OUTCOME. Incident urinary tract stone events were captured using a predefined collection of MedRA terms. A sensitivity analysis using a narrower definition was also performed. Incidence rate ratios (IRR) and 95% CIs were calculated using the relative risk estimate, stratified by study. RESULTS The median exposures to study drug were 543 days (placebo) and 549 days (empagliflozin); 183 patients experienced an incident urolithiasis during follow-up (placebo, 79; empagliflozin, 104), yielding annual incidence rates of 1.01 vs 0.63 events/100 patient-years in the 2 respective groups. The IRR was 0.64 (95% CI, 0.48-0.86), in favor of empagliflozin. In the sensitivity analysis, the results were similar (IRR, 0.62 [95% CI, 0.45-0.85]). CONCLUSION Compared with placebo, empagliflozin therapy was associated with an approximate 40% reduced risk of urinary tract stone events in T2D patients. The underlying mechanisms are unknown but may involve altered lithogenic profile of the urine. Dedicated randomized prospective clinical trials are warranted to confirm these initial observations in patients with and without T2D.
Collapse
Affiliation(s)
| | | | - João Pedro Ferreira
- Université de Lorraine, Centre d’Investigation Clinique-Plurithématique Inserm CIC-P 1433, 54500 Nancy, France Inserm U1116, CHRU Nancy Brabois, France
- Unic@RISE, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - Amelie Elsaesser
- Boehringer Ingelheim Pharma GmbH &Co KG, 55218 Ingelheim, Germany
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON M5G 1X5, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology and Metabolism, Yale School of Medicine, New Haven, CT 06520-8056, USA
| |
Collapse
|
44
|
Cherney DZI, Cosentino F, Pratley RE, Dagogo-Jack S, Frederich R, Maldonado M, Liu J, Pong A, Liu CC, Cannon CP. The differential effects of ertugliflozin on glucosuria and natriuresis biomarkers: Prespecified analyses from VERTIS CV. Diabetes Obes Metab 2022; 24:1114-1122. [PMID: 35233908 DOI: 10.1111/dom.14677] [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: 12/02/2021] [Revised: 02/17/2022] [Accepted: 02/28/2022] [Indexed: 11/27/2022]
Abstract
AIMS This prespecified exploratory analyses from VERTIS CV (NCT01986881) aimed to assess the effects of the sodium-glucose cotransporter-2 (SGLT2) inhibitor ertugliflozin on glucosuria-related (glycated haemoglobin [HbA1c], uric acid, body weight) and natriuresis-related (blood pressure, haemoglobin, haematocrit, serum albumin) biomarkers according to kidney function risk category. MATERIALS AND METHODS Patients with type 2 diabetes and atherosclerotic cardiovascular disease were randomized to placebo, ertugliflozin 5 mg, or ertugliflozin 15 mg (1:1:1). Analyses compared placebo (n = 2747) versus ertugliflozin (pooled; n = 5499) on glucosuria- and natriuresis-related biomarkers according to baseline estimated glomerular filtration rate (eGFR) subgroup and Kidney Disease: Improving Global Outcomes in Chronic Kidney Disease (KDIGO CKD) risk category. RESULTS Patients were classified according to KDIGO CKD low- (49%), moderate- (32%) and high-/very-high-risk categories (19%), and eGFR groups 1 (25%), 2 (53%) and 3 (19%). At Week 18, the high-/very-high-risk category had a smaller placebo-subtracted least squares mean (LSM) change from baseline (95% confidence interval) in HbA1c (-0.34 [-0.43, -0.25]) compared with the low- and moderate-risk categories (-0.54 [-0.60, -0.49] and - 0.47 [-0.54, -0.40], respectively). This pattern was maintained throughout the study (Pinteraction = 0.0001). Similar patterns based on baseline eGFR G stage were observed. Placebo-subtracted LSM changes from baseline in uric acid were lowest in the high-/very-high-risk category at Weeks 6 and 18, but the pattern was not maintained after Week 156 (Pinteraction = 0.15). Effects of ertugliflozin on body weight and natriuresis-related biomarkers did not differ across KDIGO CKD categories. CONCLUSIONS In VERTIS CV, ertugliflozin was associated with physiologically favourable changes in glucosuria- and natriuresis-related biomarkers. Glycaemic efficacy of ertugliflozin was attenuated in patients with higher chronic kidney disease (CKD) risk. Effects on other biomarkers were consistent, regardless of CKD risk stage.
Collapse
Affiliation(s)
- David Z I Cherney
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Francesco Cosentino
- Unit of Cardiology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Richard E Pratley
- AdventHealth Translational Research Institute, Orlando, Florida, USA
| | | | | | | | - Jie Liu
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Annpey Pong
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
45
|
Oe Y, Vallon V. The Pathophysiological Basis of Diabetic Kidney Protection by Inhibition of SGLT2 and SGLT1. KIDNEY AND DIALYSIS 2022; 2:349-368. [PMID: 36380914 PMCID: PMC9648862 DOI: 10.3390/kidneydial2020032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
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.
Collapse
Affiliation(s)
- Yuji Oe
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA
- VA San Diego Healthcare System, San Diego, CA 92161, USA
| | - Volker Vallon
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA
- VA San Diego Healthcare System, San Diego, CA 92161, USA
- Department of Pharmacology, University of California San Diego, La Jolla, CA 92161, USA
| |
Collapse
|
46
|
An Overview of the Cardiorenal Protective Mechanisms of SGLT2 Inhibitors. Int J Mol Sci 2022; 23:ijms23073651. [PMID: 35409011 PMCID: PMC8998569 DOI: 10.3390/ijms23073651] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/17/2022] [Accepted: 03/24/2022] [Indexed: 02/04/2023] Open
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors block glucose reabsorption in the renal proximal tubule, an insulin-independent mechanism that plays a critical role in glycemic regulation in diabetes. In addition to their glucose-lowering effects, SGLT2 inhibitors prevent both renal damage and the onset of chronic kidney disease and cardiovascular events, in particular heart failure with both reduced and preserved ejection fraction. These unexpected benefits prompted changes in treatment guidelines and scientific interest in the underlying mechanisms. Aside from the target effects of SGLT2 inhibition, a wide spectrum of beneficial actions is described for the kidney and the heart, even though the cardiac tissue does not express SGLT2 channels. Correction of cardiorenal risk factors, metabolic adjustments ameliorating myocardial substrate utilization, and optimization of ventricular loading conditions through effects on diuresis, natriuresis, and vascular function appear to be the main underlying mechanisms for the observed cardiorenal protection. Additional clinical advantages associated with using SGLT2 inhibitors are antifibrotic effects due to correction of inflammation and oxidative stress, modulation of mitochondrial function, and autophagy. Much research is required to understand the numerous and complex pathways involved in SGLT2 inhibition. This review summarizes the current known mechanisms of SGLT2-mediated cardiorenal protection.
Collapse
|
47
|
Suijk D, van Baar M, van Bommel E, Iqbal Z, Krebber M, Vallon V, Touw D, Hoorn E, Nieuwdorp M, Kramer M, Joles J, Bjornstad P, van Raalte D. SGLT2 Inhibition and Uric Acid Excretion in Patients with Type 2 Diabetes and Normal Kidney Function. Clin J Am Soc Nephrol 2022; 17:663-671. [PMID: 35322793 PMCID: PMC9269569 DOI: 10.2215/cjn.11480821] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/17/2022] [Indexed: 11/23/2022]
Abstract
Background and objectives: Sodium glucose transporter 2 (SGLT2)-inhibitor-induced uric acid lowering may contribute to kidney protective effects of the drug-class in people with type 2 diabetes. This study investigates mechanisms of plasma uric acid lowering by SGLT2-inhibitors in people with type 2 diabetes with a focus on urate transporter (URAT)1. Methods: We conducted an analysis of two randomized, clinical trials. First, in the Renoprotective Effects of Dapagliflozin in Type 2 Diabetes (RED) study, 44 people with type 2 diabetes were randomized to dapagliflozin or gliclazide for 12 weeks. Plasma uric acid, fractional uric acid excretion and hemodynamic kidney function were measured in the fasted state and during clamped eu- or hyperglycemia. Second, in the Uric Acid Excretion study (UREX) study, 10 people with type 2 diabetes received 1-week empagliflozin, benzbromarone and their combination in a cross-over design and effects on plasma uric acid, fractional uric acid excretion and 24-hr uric acid excretion were measured. Results: In the RED study, compared to the fasted state (5.3±1.1mg/dL), acute hyperinsulinemia and hyperglycemia significantly reduced plasma uric acid by 0.2±0.3 and 0.4±0.3 mg/dL (both p<0.001), while increasing fractional uric acid excretion (by 3.2±3.1% and 8.9±4.5% respectively (both p<0.001). Dapagliflozin reduced plasma uric acid by 0.8±0.8mg/dL, 1.0±1.0mg/dL and by 0.8±0.7mg/dL during fasting, hyperinsulinemic-euglycemic and hyperglycemic conditions (p<0.001), whereas fractional uric acid excretion in 24-hr urine increased by 3.0±2.1% (p<0.001) and 2.6±4.5% during hyperinsulinemic-euglycemic conditions (p=0.003). Fractional uric acid excretion strongly correlated to fractional glucose excretion (r= 0.35, p=0.02). In the UREX study, empagliflozin and benzbromarone both significantly reduced plasma uric acid and increased fractional uric acid excretion. Effects of combination therapy did not differ from benzbromarone monotherapy. Conclusion: In conclusion, SGLT2-inhibitors induce uric acid excretion, which is strongly linked to urinary glucose excretion and which is attenuated during concomitant pharmacological blockade of URAT1.
Collapse
Affiliation(s)
- Danii Suijk
- D Suijk, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Michaël van Baar
- M van Baar, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Erik van Bommel
- E van Bommel, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Zainab Iqbal
- Z Iqbal, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Merle Krebber
- M Krebber, Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Volker Vallon
- V Vallon, Division of Nephrology and hypertension, Department of Medicine, University of California San Diego, La Jolla, United States
| | - Daan Touw
- D Touw, Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, Netherlands
| | - Ewout Hoorn
- E Hoorn, Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands
| | - Max Nieuwdorp
- M Nieuwdorp, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Mark Kramer
- M Kramer, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| | - Jaap Joles
- J Joles, Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Petter Bjornstad
- P Bjornstad, Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, United States
| | - Daniël van Raalte
- D van Raalte, Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, Netherlands
| |
Collapse
|
48
|
Čertíková Chábová V, Zakiyanov O. Sodium Glucose Cotransporter-2 Inhibitors: Spotlight on Favorable Effects on Clinical Outcomes beyond Diabetes. Int J Mol Sci 2022; 23:ijms23052812. [PMID: 35269954 PMCID: PMC8911473 DOI: 10.3390/ijms23052812] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 12/16/2022] Open
Abstract
Sodium glucose transporter type 2 (SGLT2) molecules are found in proximal tubules of the kidney, and perhaps in the brain or intestine, but rarely in any other tissue. However, their inhibitors, intended to improve diabetes compensation, have many more beneficial effects. They improve kidney and cardiovascular outcomes and decrease mortality. These benefits are not limited to diabetics but were also found in non-diabetic individuals. The pathophysiological pathways underlying the treatment success have been investigated in both clinical and experimental studies. There have been numerous excellent reviews, but these were mostly restricted to limited aspects of the knowledge. The aim of this review is to summarize the known experimental and clinical evidence of SGLT2 inhibitors' effects on individual organs (kidney, heart, liver, etc.), as well as the systemic changes that lead to an improvement in clinical outcomes.
Collapse
|
49
|
McDowell K, Welsh P, Docherty KF, Morrow DA, Jhund PS, De Boer RA, O'Meara E, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Hammarstedt A, Langkilde AM, Sjöstrand M, Lindholm D, Solomon SD, Sattar N, Sabatine MS, McMurray JJ. Dapagliflozin reduces uric acid concentration, an independent predictor of adverse outcomes in
DAPA‐HF. Eur J Heart Fail 2022; 24:1066-1076. [PMID: 35064721 PMCID: PMC9540869 DOI: 10.1002/ejhf.2433] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/06/2022] [Accepted: 01/09/2022] [Indexed: 11/08/2022] Open
Abstract
Aims Blood uric acid (UA) levels are frequently elevated in patients with heart failure and reduced ejection fraction (HFrEF), may lead to gout and are associated with worse outcomes. Reduction in UA is desirable in HFrEF and sodium–glucose cotransporter 2 inhibitors may have this effect. We aimed to examine the association between UA and outcomes, the effect of dapagliflozin according to baseline UA level, and the effect of dapagliflozin on UA in patients with HFrEF in the DAPA‐HF trial. Methods and results The association between UA and the primary composite outcome of cardiovascular death or worsening heart failure, its components, and all‐cause mortality was examined using Cox regression analyses among 3119 patients using tertiles of UA, after adjustment for other prognostic variables. Change in UA from baseline over 12 months was also evaluated. Patients in tertile 3 (UA ≥6.8 mg/dl) versus tertile 1 (<5.4 mg/dl) were younger (66.3 ± 10.8 vs. 68 ± 10.2 years), more often male (83.1% vs. 71.5%), had lower estimated glomerular filtration rate (58.2 ± 17.4 vs. 70.6 ± 18.7 ml/min/1.73 m2), and more often treated with diuretics. Higher UA was associated with a greater risk of the primary outcome (adjusted hazard ratio tertile 3 vs. tertile 1: 1.32, 95% confidence interval [CI] 1.06–1.66; p = 0.01). The risk of heart failure hospitalization and cardiovascular death increased by 7% and 6%, respectively per 1 mg/dl unit increase of UA (p = 0.04 and p = 0.07). Spline analysis revealed a linear increase in risk above a cut‐off UA value of 7.09 mg/dl. Compared with placebo, dapagliflozin reduced UA by 0.84 mg/dl (95% CI −0.93 to −0.74) over 12 months (p < 0.001). Dapagliflozin improved outcomes, irrespective of baseline UA concentration. Conclusion Uric acid remains an independent predictor of worse outcomes in a well‐treated contemporary HFrEF population. Compared with placebo, dapagliflozin reduced UA and improved outcomes irrespective of UA concentration.
Collapse
Affiliation(s)
- Kirsty McDowell
- BHF Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Paul Welsh
- BHF Cardiovascular Research Centre University of Glasgow Glasgow UK
| | | | - David A Morrow
- Cardiovascular Division, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Rudolf A De Boer
- Department of Cardiology University Medical Center and University of Groningen Groningen Netherlands
| | - Eileen O'Meara
- Montreal Heart Institute Université de Montréal Montreal Quebec Canada
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Mikhail N. Kosiborod
- Saint Luke's Mid America Heart Institute University of Missouri Kansas City MO USA
- The George Institute for Global Health University of New South Wales Sydney Australisa
| | | | - Piotr Ponikowski
- Centre for Heart Diseases, University Hospital Wroclaw Medical University Wroclaw Poland
| | - Ann Hammarstedt
- Late Stage Development, Cardiovascular, Renal and Metabolism Biopharmaceuticals R&D Astrazeneca Gothenburg Sweden
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism Biopharmaceuticals R&D Astrazeneca Gothenburg Sweden
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism Biopharmaceuticals R&D Astrazeneca Gothenburg Sweden
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal and Metabolism Biopharmaceuticals R&D Astrazeneca Gothenburg Sweden
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | - Naveed Sattar
- BHF Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division Brigham and Women's Hospital, Harvard Medical School Boston MA USA
| | | |
Collapse
|
50
|
Nayak S, Rathore V, Bharati J, Sahu KK. Extending the ambit of SGLT2 inhibitors beyond diabetes: a review of clinical and preclinical studies on non-diabetic kidney disease. Expert Rev Clin Pharmacol 2022; 14:1513-1526. [PMID: 35020563 DOI: 10.1080/17512433.2021.2028620] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are novel antidiabetic agents with overwhelming cardiorenal protection. Recent trials focusing on the nephroprotective role of SGLT2i have underscored its success as a phenomenal agent in halting the progression of kidney disease in patients with and without Type 2 diabetes mellitus. Multitudes of pleiotropic effects on tubules have raised hopes for reasonable nephroprotection beyond the purview of the hyperglycemic milieu. AREA COVERED This review summarizes various animal and human data as evidence for the utility of SGLT2i in non-diabetic chronic kidney disease (CKD). Web-based medical database entries were searched. On the premise of existing evidence, we have discussed mechanisms likely contributing to nephroprotection by SGLT2i in patients with non-diabetic CKD. EXPERT OPINION Further elucidation of mechanisms of nephroprotection offered by SGLT2i is required to extend its use as a nephroprotective agent. The use of non-traditional markers of kidney damage in future studies would improve the evaluation of their role in attenuating CKD progression. Emerging animal data support the early use of SGLT2i in states of modest proteinuria for superior outcomes. Future long-term trials in patients should aim to address the time of intervention with SGLT2i during the natural disease course of CKD for best outcomes.
Collapse
Affiliation(s)
- Saurabh Nayak
- Department of Nephrology, All India Institute of Medical Science, Raipur, India
| | - Vinay Rathore
- Department of Nephrology, All India Institute of Medical Science, Raipur, India
| | - Joyita Bharati
- Department of Nephrology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Kamal Kant Sahu
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah Salt Lake City, Zip 84112, Utah, USA
| |
Collapse
|