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Edwards A. Renal handling of albumin in rats with early stage diabetes: A theoretical analysis. J Physiol 2024. [PMID: 38857419 DOI: 10.1113/jp286245] [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: 01/08/2024] [Accepted: 05/20/2024] [Indexed: 06/12/2024] Open
Abstract
In early diabetic nephropathy (DN), recent studies have shown that albuminuria stems mostly from alterations in tubular function rather than from glomerular damage. Several factors in DN, including hyperfiltration, hypertrophy and reduced abundance of the albumin receptors megalin and cubilin, affect albumin endocytosis in the proximal tubule (PT). To assess their respective contribution, we developed a model of albumin handling in the rat PT that couples the transport of albumin to that of water and solutes. Our simulations suggest that, under basal conditions, ∼75% of albumin is retrieved in the S1 segment. The model predicts negligible uptake in S3, as observed experimentally. It also accurately predicts the impact of acute hyperglycaemia on urinary albumin excretion. Simulations reproduce observed increases in albumin excretion in early DN by considering the combined effects of increased glomerular filtration rate (GFR), osmotic diuresis, hypertrophy, and megalin and cubilin downregulation, without stipulating changes in glomerular permselectivity. The results indicate that in isolation, glucose-elicited osmotic diuresis and glucose transporter upregulation raise albumin excretion only slightly. Enlargement of PT diameter not only augments uptake via surface area expansion, but also reduces fluid velocity and thus shear stress-induced stimulation of endocytosis. Overall, our model predicts that downregulation of megalin and cubilin and hyperfiltration both contribute significantly to increasing albumin excretion in rats with early-stage diabetes. The results also suggest that acute sodium-glucose cotransporter 2 inhibition lowers albumin excretion only if GFR decreases sufficiently, and that angiotensin II receptor blockers mitigate urinary albumin loss in early DN in large part by upregulating albumin receptor abundance. KEY POINTS: The urinary excretion of albumin is increased in early diabetic nephropathy (DN). It is difficult to experimentally disentangle the multiple factors that affect the renal handling of albumin in DN. We developed a mathematical model of albumin transport in the rat proximal tubule (PT) to examine the impact of elevated plasma glucose, hyperfiltration, PT hypertrophy and reduced abundance of albumin receptors on albumin uptake and excretion in DN. Our model predicts that glucose-elicited osmotic diuresis per se raises albumin excretion only slightly. Conversely, increases in PT diameter and length favour reduced albumin excretion. Our results suggest that downregulation of the receptors megalin and cubilin in PT cells and hyperfiltration both contribute significantly to increasing albumin excretion in DN. The model helps to better understand the mechanisms underlying urinary loss of albumin in early-stage diabetes, and the impact of specific treatments thereupon.
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Affiliation(s)
- Aurélie Edwards
- Department of Biomedical Engineering, Boston University, Boston, MA, USA
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2
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Upadhyay A. SGLT2 Inhibitors and Kidney Protection: Mechanisms Beyond Tubuloglomerular Feedback. KIDNEY360 2024; 5:771-782. [PMID: 38523127 PMCID: PMC11146657 DOI: 10.34067/kid.0000000000000425] [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: 09/11/2023] [Accepted: 03/19/2024] [Indexed: 03/26/2024]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk for kidney failure and are a key component of guideline-directed therapy for CKD. While SGLT2 inhibitors' ability to activate tubuloglomerular feedback and reduce hyperfiltration-mediated kidney injury is considered to be the central mechanism for kidney protection, recent data from experimental studies raise questions on the primacy of this mechanism. This review examines SGLT2 inhibitors' role in tubuloglomerular feedback and summarizes emerging evidence on following of SGLT2 inhibitors' other putative mechanisms for kidney protection: optimization of kidney's energy substrate utilization and delivery, regulation of autophagy and maintenance of cellular homeostasis, attenuation of sympathetic hyperactivity, and improvement in vascular health and microvascular function. It is imperative to examine the effect of SGLT2 inhibition on these different physiologic processes to help our understanding of mechanisms underpinning kidney protection with this important class of drugs.
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Affiliation(s)
- Ashish Upadhyay
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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3
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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.
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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
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Yang W, Liu X, He Z, Zhang Y, Tan X, Liu C. odd skipped-related 2 as a novel mark for labeling the proximal convoluted tubule within the zebrafish kidney. Heliyon 2024; 10:e27582. [PMID: 38496848 PMCID: PMC10944271 DOI: 10.1016/j.heliyon.2024.e27582] [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: 07/18/2023] [Revised: 12/15/2023] [Accepted: 03/03/2024] [Indexed: 03/19/2024] Open
Abstract
The proximal convoluted tubule (PCT) of the kidney is a crucial functional segment responsible for reabsorption, secretion, and the maintenance of electrolyte and water balance within the renal tubule. However, there is a lack of a well-defined endogenous transgenic line for studying PCT morphogenesis. By analyzing single-cell transcriptome data from the adult zebrafish kidney, we have identified the expression of odd-skipped-related 2 (osr2, which encodes an odd-skipped zinc-finger transcription factor) in the PCT. To gain insight into the role of osr2 in PCT morphogenesis, we have generated a transgenic zebrafish line Tg(osr2:EGFP), expressing enhanced green fluorescent protein (EGFP). The EGFP expression pattern closely mirrors that of endogenous Osr2, faithfully recapitulating its native expression profile. During kidney development, we can use EGFP to track PCT development, which is also preserved in adult zebrafish. Additionally, osr2:EGFP-labeled zebrafish PCT fragments displayed short lengths with infrequent overlap, rendering them conducive for nephrons counting. The generation of Tg(osr2:EGFP) transgenic line is accompanied by simultaneous disruption of osr2 activity. Importantly, our findings demonstrate that osr2 inactivation had no discernible impact on the development and regeneration of Tg(osr2:EGFP) zebrafish nephrons. Overall, the establishment of this transgenic zebrafish line offers a valuable tool for both genetic and chemical analysis of PCT.
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Affiliation(s)
- Wenmin Yang
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), 400037, Chongqing, PR China
| | - Xiaoliang Liu
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), 400037, Chongqing, PR China
| | - Zhongwei He
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), 400037, Chongqing, PR China
| | - Yunfeng Zhang
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), 400037, Chongqing, PR China
| | - Xiaoqin Tan
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), 400037, Chongqing, PR China
| | - Chi Liu
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), 400037, Chongqing, PR China
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Reiss AB, Jacob B, Zubair A, Srivastava A, Johnson M, De Leon J. Fibrosis in Chronic Kidney Disease: Pathophysiology and Therapeutic Targets. J Clin Med 2024; 13:1881. [PMID: 38610646 PMCID: PMC11012936 DOI: 10.3390/jcm13071881] [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: 02/14/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
Chronic kidney disease (CKD) is a slowly progressive condition characterized by decreased kidney function, tubular injury, oxidative stress, and inflammation. CKD is a leading global health burden that is asymptomatic in early stages but can ultimately cause kidney failure. Its etiology is complex and involves dysregulated signaling pathways that lead to fibrosis. Transforming growth factor (TGF)-β is a central mediator in promoting transdifferentiation of polarized renal tubular epithelial cells into mesenchymal cells, resulting in irreversible kidney injury. While current therapies are limited, the search for more effective diagnostic and treatment modalities is intensive. Although biopsy with histology is the most accurate method of diagnosis and staging, imaging techniques such as diffusion-weighted magnetic resonance imaging and shear wave elastography ultrasound are less invasive ways to stage fibrosis. Current therapies such as renin-angiotensin blockers, mineralocorticoid receptor antagonists, and sodium/glucose cotransporter 2 inhibitors aim to delay progression. Newer antifibrotic agents that suppress the downstream inflammatory mediators involved in the fibrotic process are in clinical trials, and potential therapeutic targets that interfere with TGF-β signaling are being explored. Small interfering RNAs and stem cell-based therapeutics are also being evaluated. Further research and clinical studies are necessary in order to avoid dialysis and kidney transplantation.
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Affiliation(s)
- Allison B. Reiss
- Department of Medicine and Biomedical Research Institute, NYU Grossman Long Island School of Medicine, Mineola, NY 11501, USA; (B.J.); (A.Z.); (A.S.); (M.J.); (J.D.L.)
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Chuang MH, Tang YS, Chen JY, Pan HC, Liao HW, Chu WK, Cheng CY, Wu VC, Heung M. Abrupt Decline in Estimated Glomerular Filtration Rate after Initiating Sodium-Glucose Cotransporter 2 Inhibitors Predicts Clinical Outcomes: A Systematic Review and Meta-Analysis. Diabetes Metab J 2024; 48:242-252. [PMID: 38273790 PMCID: PMC10995480 DOI: 10.4093/dmj.2023.0201] [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: 06/24/2023] [Accepted: 09/25/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGRUOUND The initiation of sodium-glucose cotransporter-2 inhibitors (SGLT2i) typically leads to a reversible initial dip in estimated glomerular filtration rate (eGFR). The implications of this phenomenon on clinical outcomes are not well-defined. METHODS We searched MEDLINE, Embase, and Cochrane Library from inception to March 23, 2023 to identify randomized controlled trials and cohort studies comparing kidney and cardiovascular outcomes in patients with and without initial eGFR dip after initiating SGLT2i. Pooled estimates were calculated using random-effect meta-analysis. RESULTS We included seven studies in our analysis, which revealed that an initial eGFR dip following the initiation of SGLT2i was associated with less annual eGFR decline (mean difference, 0.64; 95% confidence interval [CI], 0.437 to 0.843) regardless of baseline eGFR. The risk of major adverse kidney events was similar between the non-dipping and dipping groups but reduced in patients with a ≤10% eGFR dip (hazard ratio [HR], 0.915; 95% CI, 0.865 to 0.967). No significant differences were observed in the composite of hospitalized heart failure and cardiovascular death (HR, 0.824; 95% CI, 0.633 to 1.074), hospitalized heart failure (HR, 1.059; 95% CI, 0.574 to 1.952), or all-cause mortality (HR, 0.83; 95% CI, 0.589 to 1.170). The risk of serious adverse events (AEs), discontinuation of SGLT2i due to AEs, kidney-related AEs, and volume depletion were similar between the two groups. Patients with >10% eGFR dip had increased risk of hyperkalemia compared to the non-dipping group. CONCLUSION Initial eGFR dip after initiating SGLT2i might be associated with less annual eGFR decline. There were no significant disparities in the risks of adverse cardiovascular outcomes between the dipping and non-dipping groups.
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Affiliation(s)
- Min-Hsiang Chuang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Shuo Tang
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University Research Center of Urology and Kidney, Taipei, Taiwan
| | - Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Heng-Chih Pan
- Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Hung-Wei Liao
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Kai Chu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chung-Yi Cheng
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University Research Center of Urology and Kidney, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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Martínez-Rojas MÁ, Balcázar H, González-Soria I, González-Rivera JM, Rodríguez-Vergara ME, Velazquez-Villegas LA, León-Contreras JC, Pérez-Villalva R, Correa F, Rosetti F, Bobadilla NA. Transient inhibition of sodium-glucose cotransporter 2 after ischemia/reperfusion injury ameliorates chronic kidney disease. JCI Insight 2024; 9:e173675. [PMID: 38516890 PMCID: PMC11063941 DOI: 10.1172/jci.insight.173675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/08/2024] [Indexed: 03/23/2024] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitor, dapagliflozin (Dapa), exhibited nephroprotective effects in patients with chronic kidney disease (CKD). We assessed the efficacy of short-term Dapa administration following acute kidney injury (AKI) in preventing CKD. Male Wistar rats were randomly assigned to Sham surgery, bilateral ischemia for 30 minutes (abbreviated as IR), and IR + Dapa groups. Daily treatment with Dapa was initiated just 24 hours after IR and maintained for only 10 days. Initially, rats were euthanized at this point to study early renal repair. After severe AKI, Dapa promptly restored creatinine clearance (CrCl) and significantly reduced renal vascular resistance compared with the IR group. Furthermore, Dapa effectively reversed the mitochondrial abnormalities, including increased fission, altered mitophagy, metabolic dysfunction, and proapoptotic signaling. To study this earlier, another set of rats was studied just 5 days after AKI. Despite persistent renal dysfunction, our data reveal a degree of mitochondrial protection. Remarkably, a 10-day treatment with Dapa demonstrated effectiveness in preventing CKD transition in an independent cohort monitored for 5 months after AKI. This was evidenced by improvements in proteinuria, CrCl, glomerulosclerosis, and fibrosis. Our findings underscore the potential of Dapa in preventing maladaptive repair following AKI, emphasizing the crucial role of early intervention in mitigating AKI long-term consequences.
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Affiliation(s)
- Miguel Ángel Martínez-Rojas
- Unidad de Fisiología Molecular, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departmento de Nefrología y Metabolismo Mineral
| | - Hiram Balcázar
- Unidad de Fisiología Molecular, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departmento de Nefrología y Metabolismo Mineral
| | - Isaac González-Soria
- Unidad de Fisiología Molecular, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departmento de Nefrología y Metabolismo Mineral
| | - Jesús Manuel González-Rivera
- Unidad de Fisiología Molecular, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departmento de Nefrología y Metabolismo Mineral
| | - Mauricio E. Rodríguez-Vergara
- Unidad de Fisiología Molecular, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departmento de Nefrología y Metabolismo Mineral
| | | | - Juan Carlos León-Contreras
- Departmento de Patología Experimental, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rosalba Pérez-Villalva
- Unidad de Fisiología Molecular, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departmento de Nefrología y Metabolismo Mineral
| | - Francisco Correa
- Departmento de Biomedicina Cardiovascular, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Florencia Rosetti
- Departmento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Norma A. Bobadilla
- Unidad de Fisiología Molecular, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
- Departmento de Nefrología y Metabolismo Mineral
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8
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Neumiller JJ, Alicic RZ, Tuttle KR. Optimization of guideline-directed medical therapies in patients with diabetes and chronic kidney disease. Clin Kidney J 2024; 17:sfad285. [PMID: 38213492 PMCID: PMC10783256 DOI: 10.1093/ckj/sfad285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Indexed: 01/13/2024] Open
Abstract
Diabetes is the leading cause of chronic kidney disease (CKD) and kidney failure worldwide. CKD frequently coexists with heart failure and atherosclerotic cardiovascular disease in the broader context of cardio-kidney-metabolic syndrome. Diabetes and CKD are associated with increased risk of all-cause and cardiovascular death as well as decreased quality of life. The role of metabolic and hemodynamic abnormalities has long been recognized as an important contributor to the pathogenesis and progression of CKD in diabetes, while a more recent and growing body of evidence supports activation of both systemic and local inflammation as important contributors. Current guidelines recommend therapies targeting pathomechanisms of CKD in addition to management of traditional risk factors such as hyperglycemia and hypertension. Sodium-glucose cotransporter-2 inhibitors are recommended for treatment of patients with CKD and type 2 diabetes (T2D) if eGFR is ≥20 ml/min/173 m2 on a background of renin-angiotensin system inhibition. For patients with T2D, CKD, and atherosclerotic cardiovascular disease, a glucagon-like peptide-1 receptor agonist is recommended as additional risk-based therapy. A non-steroidal mineralocorticoid receptor antagonist is also recommended as additional risk-based therapy for persistent albuminuria in patients with T2D already treated with renin-angiotensin system inhibition. Implementation of guideline-directed medical therapies is challenging in the face of rapidly accumulating knowledge, high cost of medications, and lack of infrastructure for optimal healthcare delivery. Furthermore, studies of new therapies have focused on T2D and CKD. Clinical trials are now planned to inform the role of these therapies in people with type 1 diabetes (T1D) and CKD.
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Affiliation(s)
- Joshua J Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA, USA
| | - Radica Z Alicic
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Nephrology Division, Kidney Research Institute, and Institute of Translational Health Sciences, University of Washington, Seattle, WA, USA
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9
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Mogi M, Tanaka A, Node K, Tomitani N, Hoshide S, Narita K, Nozato Y, Katsurada K, Maruhashi T, Higashi Y, Matsumoto C, Bokuda K, Yoshida Y, Shibata H, Toba A, Masuda T, Nagata D, Nagai M, Shinohara K, Kitada K, Kuwabara M, Kodama T, Kario K. 2023 update and perspectives. Hypertens Res 2024; 47:6-32. [PMID: 37710033 DOI: 10.1038/s41440-023-01398-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/30/2023] [Indexed: 09/16/2023]
Abstract
Total 276 manuscripts were published in Hypertension Research in 2022. Here our editorial members picked up the excellent papers, summarized the current topics from the published papers and discussed future perspectives in the sixteen fields. We hope you enjoy our special feature, 2023 update and perspectives in Hypertension Research.
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Affiliation(s)
- Masaki Mogi
- Deparment of Pharmacology, Ehime University Graduate School of Medicine, 454 Shitsukawa Tohon, Ehime, 791-0295, Japan.
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-1-1, Nabeshima, Saga, Saga, 849-8501, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-1-1, Nabeshima, Saga, Saga, 849-8501, Japan
| | - Naoko Tomitani
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Keisuke Narita
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yoichi Nozato
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Kenichi Katsurada
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
- Division of Clinical Pharmacology, Department of Pharmacology, Jichi Medical University School of Medicine, 3311-1, Shimotsuke, Tochigi, 329-0498, Japan
| | - Tatsuya Maruhashi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan
| | - Yukihito Higashi
- Department of Regenerative Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan
- Divivsion of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Chisa Matsumoto
- Center for Health Surveillance & Preventive Medicine, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
- Department of Cardiology, Tokyo Medical University, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan
| | - Kanako Bokuda
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yuichi Yoshida
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu city, Oita, 879-5593, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu city, Oita, 879-5593, Japan
| | - Ayumi Toba
- Tokyo Metropolitan Institute for Geriatrics and Gerontology, Sakaecho, Itabashi-ku, Tokyo, 173-0015, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Michiaki Nagai
- Cardiovascular Section, Department of Internal Medicine, Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, 800 SL Young Blvd, COM 5400, Oklahoma City, OK, 73104, USA
- Department of Cardiology, Hiroshima City Asa Hospital, 1-2-1 Kameyamaminami Asakita-ku, Hiroshima, 731-0293, Japan
| | - Keisuke Shinohara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kento Kitada
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Miki, Kita, Kagawa, 761-0793, Japan
| | - Masanari Kuwabara
- Department of Cardiology, Toranomon Hospital, 2-2-2, Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Takahide Kodama
- Department of Cardiology, Toranomon Hospital, 2-2-2, Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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10
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Clemmer JS, Yen TE, Obi Y. Modeling the renoprotective mechanisms of SGLT2 inhibition in hypertensive chronic kidney disease. Physiol Rep 2023; 11:e15836. [PMID: 37957121 PMCID: PMC10643202 DOI: 10.14814/phy2.15836] [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: 08/01/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 11/15/2023] Open
Abstract
Sodium-glucose cotransporter (SGLT)-2 inhibitors have recently been approved for chronic kidney disease (CKD) based on their ability to lower proteinuria and slow CKD progression independent of diabetes status. In diabetic renal disease, modulation of tubuloglomerular feedback (TGF) leading to lower intraglomerular pressure has been postulated as one of the mechanisms of renal protection with SGLT2 inhibition; however, this mechanism has not been sufficiently explored in non-diabetic CKD. We hypothesized that SGLT2 inhibition exerts renoprotection in CKD through increasing TGF despite normoglycemia. To test this hypothesis, we used an integrative mathematical model of human physiology, HumMod. Stage 3 CKD conditions were simulated by reducing nephron mass which was associated with hypertension, low glomerular filtration rate (GFR) (55 mL/min), hyperfiltration of remnant nephrons, elevated albuminuria (500 mg/day), and minimal levels of urinary glucose (0.02 mmol/L). SGLT2 inhibition was associated with acute reductions in GFR associated with afferent arteriolar vasoconstriction due to TGF. After 12 months, glomerular pressure, nephron damage, and chronic GFR decline were reduced with SGLT2 inhibition with additional SGLT1 inhibitory effects further enhancing these effects. This model supports the use of SGLT2 inhibitors to reduce hyperfiltration in CKD and mitigate renal disease progression, even in the absence of diabetes.
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Affiliation(s)
- John S. Clemmer
- Department of Physiology and BiophysicsUniversity of Mississippi Medical CenterJacksonMississippiUSA
| | - Timothy E. Yen
- Department of Medicine, Division of NephrologyUniversity of Mississippi Medical CenterJacksonMississippiUSA
| | - Yoshitsugu Obi
- Department of Medicine, Division of NephrologyUniversity of Mississippi Medical CenterJacksonMississippiUSA
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11
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Chen X, Hocher CF, Shen L, Krämer BK, Hocher B. Reno- and cardioprotective molecular mechanisms of SGLT2 inhibitors beyond glycemic control: from bedside to bench. Am J Physiol Cell Physiol 2023; 325:C661-C681. [PMID: 37519230 DOI: 10.1152/ajpcell.00177.2023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/01/2023]
Abstract
Large placebo-controlled clinical trials have shown that sodium-glucose cotransporter-2 inhibitors (SGLT2i) delay the deterioration of renal function and reduce cardiovascular events in a glucose-independent manner, thereby ultimately reducing mortality in patients with chronic kidney disease (CKD) and/or heart failure. These existing clinical data stimulated preclinical studies aiming to understand the observed clinical effects. In animal models, it was shown that the beneficial effect of SGLT2i on the tubuloglomerular feedback (TGF) improves glomerular pressure and reduces tubular workload by improving renal hemodynamics, which appears to be dependent on salt intake. High salt intake might blunt the SGLT2i effects on the TGF. Beyond the salt-dependent effects of SGLT2i on renal hemodynamics, SGLT2i inhibited several key aspects of macrophage-mediated renal inflammation and fibrosis, including inhibiting the differentiation of monocytes to macrophages, promoting the polarization of macrophages from a proinflammatory M1 phenotype to an anti-inflammatory M2 phenotype, and suppressing the activation of inflammasomes and major proinflammatory factors. As macrophages are also important cells mediating atherosclerosis and myocardial remodeling after injury, the inhibitory effects of SGLT2i on macrophage differentiation and inflammatory responses may also play a role in stabilizing atherosclerotic plaques and ameliorating myocardial inflammation and fibrosis. Recent studies suggest that SGLT2i may also act directly on the Na+/H+ exchanger and Late-INa in cardiomyocytes thus reducing Na+ and Ca2+ overload-mediated myocardial damage. In addition, the renal-cardioprotective mechanisms of SGLT2i include systemic effects on the sympathetic nervous system, blood volume, salt excretion, and energy metabolism.
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Affiliation(s)
- Xin Chen
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Carl-Friedrich Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
- Klinik für Innere Medizin, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | - Linghong Shen
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bernhard K Krämer
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Berthold Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Institute of Reproductive and Stem Cell Engineering, NHC Key Laboratory of Human Stem Cell and Reproductive Engineering, School of Basic Medical Science, Central South University, Changsha, China
- IMD Institut für Medizinische Diagnostik Berlin-Potsdam GbR, Berlin, Germany
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12
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Kunke M, Knöfler H, Dahlke E, Zanon Rodriguez L, Böttner M, Larionov A, Saudenova M, Ohrenschall GM, Westermann M, Porubsky S, Bernardes JP, Häsler R, Magnin JL, Koepsell H, Jouret F, Theilig F. Targeted deletion of von-Hippel-Lindau in the proximal tubule conditions the kidney against early diabetic kidney disease. Cell Death Dis 2023; 14:562. [PMID: 37626062 PMCID: PMC10457389 DOI: 10.1038/s41419-023-06074-7] [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: 04/19/2023] [Revised: 08/01/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023]
Abstract
Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease. Glomerular hyperfiltration and albuminuria subject the proximal tubule (PT) to a subsequent elevation of workload, growth, and hypoxia. Hypoxia plays an ambiguous role in the development and progression of DKD and shall be clarified in our study. PT-von-Hippel-Lindau (Vhl)-deleted mouse model in combination with streptozotocin (STZ)-induced type I diabetes mellitus (DM) was phenotyped. In contrary to PT-Vhl-deleted STZ-induced type 1 DM mice, proteinuria and glomerular hyperfiltration occurred in diabetic control mice the latter due to higher nitric oxide synthase 1 and sodium and glucose transporter expression. PT Vhl deletion and DKD share common alterations in gene expression profiles, including glomerular and tubular morphology, and tubular transport and metabolism. Compared to diabetic control mice, the most significantly altered in PT Vhl-deleted STZ-induced type 1 DM mice were Ldc-1, regulating cellular oxygen consumption rate, and Zbtb16, inhibiting autophagy. Alignment of altered genes in heat maps uncovered that Vhl deletion prior to STZ-induced DM preconditioned the kidney against DKD. HIF-1α stabilization leading to histone modification and chromatin remodeling resets most genes altered upon DKD towards the control level. These data demonstrate that PT HIF-1α stabilization is a hallmark of early DKD and that targeting hypoxia prior to the onset of type 1 DM normalizes renal cell homeostasis and prevents DKD development.
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Affiliation(s)
- Madlen Kunke
- Institute of Anatomy, Christian Albrechts-University Kiel, Kiel, Germany
| | - Hannah Knöfler
- Institute of Anatomy, Christian Albrechts-University Kiel, Kiel, Germany
| | - Eileen Dahlke
- Institute of Anatomy, Christian Albrechts-University Kiel, Kiel, Germany
| | | | - Martina Böttner
- Institute of Anatomy, Christian Albrechts-University Kiel, Kiel, Germany
| | - Alexey Larionov
- Institute of Anatomy, Department of Medicine, University of Fribourg, Fribourg, Switzerland
| | | | | | | | | | - Joana P Bernardes
- Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Robert Häsler
- Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Hermann Koepsell
- Institute of Anatomy and Cell Biology, Julius-Maximilians-University of Würzburg, Würzburg, Germany
| | - François Jouret
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA), Cardiovascular Sciences, University of Liège (ULiège), Liège, Belgium
- Division of Nephrology, CHU of Liège, University of Liège (CHU ULiège), Liège, Belgium
| | - Franziska Theilig
- Institute of Anatomy, Christian Albrechts-University Kiel, Kiel, Germany.
- Institute of Anatomy, Department of Medicine, University of Fribourg, Fribourg, Switzerland.
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13
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Chen S, Song X, Xiao Q, Wang L, Zhu X, Zou Y, Li G. Knockdown of TMEM30A in renal tubular epithelial cells leads to reduced glucose absorption. BMC Nephrol 2023; 24:250. [PMID: 37612668 PMCID: PMC10464243 DOI: 10.1186/s12882-023-03299-8] [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: 10/23/2022] [Accepted: 08/16/2023] [Indexed: 08/25/2023] Open
Abstract
The kidney reabsorbs large amounts of glucose through Na+-glucose cotransporter 2 (SGLT2). P4-ATPase acts together with the β-subunit TMEM30A to mediate the asymmetric distribution of phosphatidylserine (PS), phosphatidylethanolamine (PE), and other amino phospholipids, promoting plasma membrane and internal vesicle fusion, and facilitating vesicle protein transport. We observed reduced TMEM30A expression in renal tubules of DKD and IgA patients, suggesting a potential role of TMEM30A in renal tubular cells. To investigate the role of TMEM30A in renal tubules, we constructed a TMEM30A knockdown cell model by transfecting mouse kidney tubular epithelium cells (TCMK-1) with TMEM30A shRNA. Knockdown of TMEM30A in TCMK-1 cells attenuated vesicle transporter protein synthesis, resulting in reduced transport and expression of SGLT2, which in turn reduced glucose absorption. These data suggested that TMEM30A plays a crucial role in renal tubules.
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Affiliation(s)
- Sipei Chen
- Department of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West 2Nd Duan, 1St Circle Road, Qingyang District, Chengdu, 610072, Sichuan, China
| | - Xinrou Song
- Department of Nephrology, Chengdu Fifth People's Hospital, Chengdu, China
| | - Qiong Xiao
- Department of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West 2Nd Duan, 1St Circle Road, Qingyang District, Chengdu, 610072, Sichuan, China
| | - Li Wang
- Department of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West 2Nd Duan, 1St Circle Road, Qingyang District, Chengdu, 610072, Sichuan, China
| | - Xianjun Zhu
- Department of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West 2Nd Duan, 1St Circle Road, Qingyang District, Chengdu, 610072, Sichuan, China
| | - Yang Zou
- Department of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West 2Nd Duan, 1St Circle Road, Qingyang District, Chengdu, 610072, Sichuan, China
| | - Guisen Li
- Department of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West 2Nd Duan, 1St Circle Road, Qingyang District, Chengdu, 610072, Sichuan, China.
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14
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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
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15
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Hoehlschen J, Hofreither D, Tomin T, Birner-Gruenberger R. Redox-driven cardioprotective effects of sodium-glucose co-transporter-2 inhibitors: comparative review. Cardiovasc Diabetol 2023; 22:101. [PMID: 37120524 PMCID: PMC10148992 DOI: 10.1186/s12933-023-01822-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/03/2023] [Indexed: 05/01/2023] Open
Abstract
Sodium-glucose co-transporter-2 inhibitors are used in the treatment of diabetes but are also emerging as cardioprotective agents in heart diseases even in the absence of type 2 diabetes. In this paper, upon providing a short overview of common pathophysiological features of diabetes, we review the clinically reported cardio- and nephroprotective potential of sodium-glucose co-transporter-2 inhibitors currently available on the market, including Dapagliflozin, Canagliflozin, and Empagliflozin. To that end, we summarize findings of clinical trials that have initially drawn attention to the drugs' organ-protective potential, before providing an overview of their proposed mechanism of action. Since we particularly expect that their antioxidative properties will broaden the application of gliflozins from therapeutic to preventive care, special emphasis was put on this aspect.
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Affiliation(s)
- Julia Hoehlschen
- Institute of Chemical Technologies and Analytics, TU Wien, Wien, Austria
| | - Dominik Hofreither
- Institute of Chemical Technologies and Analytics, TU Wien, Wien, Austria
| | - Tamara Tomin
- Institute of Chemical Technologies and Analytics, TU Wien, Wien, Austria.
| | - Ruth Birner-Gruenberger
- Institute of Chemical Technologies and Analytics, TU Wien, Wien, Austria.
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria.
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16
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Jones NK, Costello HM, Monaghan MT, Stewart K, Binnie D, Marks J, Bailey MA, Culshaw GJ. Sodium-glucose cotransporter 2 inhibition does not improve the acute pressure natriuresis response in rats with type 1 diabetes. Exp Physiol 2023; 108:480-490. [PMID: 36644793 PMCID: PMC10103849 DOI: 10.1113/ep090849] [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: 09/26/2022] [Accepted: 12/19/2022] [Indexed: 01/17/2023]
Abstract
NEW FINDINGS What is the central question of this study? Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce cardiovascular risk in patients with both diabetic and non-diabetic kidney disease: can SGLT2 inhibition improve renal pressure natriuresis (PN), an important mechanism for long-term blood pressure control, which is impaired in type 1 diabetes mellitus (T1DM)? What is the main finding and its importance? The SGLT2 inhibitor dapagliflozin did not enhance the acute in vivo PN response in either healthy or T1DM Sprague-Dawley rats. The data suggest that the mechanism underpinning the clinical benefits of SGLT2 inhibitors on health is unlikely to be due to an enhanced natriuretic response to increased blood pressure. ABSTRACT Type 1 diabetes mellitus (T1DM) leads to serious complications including premature cardiovascular and kidney disease. Hypertension contributes importantly to these adverse outcomes. The renal pressure natriuresis (PN) response, a key regulator of blood pressure (BP), is impaired in rats with T1DM as tubular sodium reabsorption fails to down-regulate with increasing BP. We hypothesised that sodium-glucose cotransporter 2 (SGLT2) inhibitors, which reduce cardiovascular risk in kidney disease, would augment the PN response in T1DM rats. Non-diabetic or T1DM (35-50 mg/kg streptozotocin i.p.) adult male Sprague-Dawley rats were anaesthetised (thiopental 50 mg/kg i.p.) and randomised to receive either dapagliflozin (1 mg/kg i.v.) or vehicle. Baseline sodium excretion was measured and then BP was increased by sequential arterial ligations to induce the PN response. In non-diabetic animals, the natriuretic and diuretic responses to increasing BP were not augmented by dapagliflozin. Dapagliflozin induced glycosuria, but this was not influenced by BP. In T1DM rats the PN response was impaired. Dapagliflozin again increased urinary glucose excretion but did not enhance PN. Inhibition of SGLT2 does not enhance the PN response in rats, either with or without T1DM. SGLT2 makes only a minor contribution to tubular sodium reabsorption and does not contribute to the impaired PN response in T1DM.
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Affiliation(s)
- Natalie K. Jones
- British Heart Foundation Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | - Hannah M. Costello
- British Heart Foundation Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | | | - Kevin Stewart
- British Heart Foundation Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | - David Binnie
- British Heart Foundation Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | - Joanne Marks
- Department of NeurosciencePhysiology and Pharmacology, Royal Free CampusUniversity College LondonLondonUK
| | - Matthew A. Bailey
- British Heart Foundation Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | - Geoffrey J. Culshaw
- British Heart Foundation Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
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17
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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.
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18
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Staruschenko A, Ma R, Palygin O, Dryer SE. Ion channels and channelopathies in glomeruli. Physiol Rev 2023; 103:787-854. [PMID: 36007181 PMCID: PMC9662803 DOI: 10.1152/physrev.00013.2022] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/15/2022] [Accepted: 08/21/2022] [Indexed: 11/22/2022] Open
Abstract
An essential step in renal function entails the formation of an ultrafiltrate that is delivered to the renal tubules for subsequent processing. This process, known as glomerular filtration, is controlled by intrinsic regulatory systems and by paracrine, neuronal, and endocrine signals that converge onto glomerular cells. In addition, the characteristics of glomerular fluid flow, such as the glomerular filtration rate and the glomerular filtration fraction, play an important role in determining blood flow to the rest of the kidney. Consequently, disease processes that initially affect glomeruli are the most likely to lead to end-stage kidney failure. The cells that comprise the glomerular filter, especially podocytes and mesangial cells, express many different types of ion channels that regulate intrinsic aspects of cell function and cellular responses to the local environment, such as changes in glomerular capillary pressure. Dysregulation of glomerular ion channels, such as changes in TRPC6, can lead to devastating glomerular diseases, and a number of channels, including TRPC6, TRPC5, and various ionotropic receptors, are promising targets for drug development. This review discusses glomerular structure and glomerular disease processes. It also describes the types of plasma membrane ion channels that have been identified in glomerular cells, the physiological and pathophysiological contexts in which they operate, and the pathways by which they are regulated and dysregulated. The contributions of these channels to glomerular disease processes, such as focal segmental glomerulosclerosis (FSGS) and diabetic nephropathy, as well as the development of drugs that target these channels are also discussed.
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Affiliation(s)
- Alexander Staruschenko
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
- Hypertension and Kidney Research Center, University of South Florida, Tampa, Florida
- James A. Haley Veterans Hospital, Tampa, Florida
| | - Rong Ma
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas
| | - Oleg Palygin
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Stuart E Dryer
- Department of Biology and Biochemistry, University of Houston, Houston, Texas
- Department of Biomedical Sciences, Tilman J. Fertitta Family College of Medicine, University of Houston, Houston, Texas
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19
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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.
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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.
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20
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Heyman SN, Raz I, Dwyer JP, Weinberg Sibony R, Lewis JB, Abassi Z. Diabetic Proteinuria Revisited: Updated Physiologic Perspectives. Cells 2022; 11:cells11182917. [PMID: 36139492 PMCID: PMC9496872 DOI: 10.3390/cells11182917] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/11/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
Albuminuria, a hallmark of diabetic nephropathy, reflects not only injury and dysfunction of the filtration apparatus, but is also affected by altered glomerular hemodynamics and hyperfiltration, as well as by the inability of renal tubular cells to fully retrieve filtered albumin. Albuminuria further plays a role in the progression of diabetic nephropathy, and the suppression of glomerular albumin leak is a key factor in its prevention. Although microalbuminuria is a classic manifestation of diabetic nephropathy, often progressing to macroalbuminuria or overt proteinuria over time, it does not always precede renal function loss in diabetes. The various components leading to diabetic albuminuria and their associations are herein reviewed, and the physiologic rationale and efficacy of therapeutic interventions that reduce glomerular hyperfiltration and proteinuria are discussed. With these perspectives, we propose that these measures should be initiated early, before microalbuminuria develops, as substantial renal injury may already be present in the absence of proteinuria. We further advocate that the inhibition of the renin–angiotensin axis or of sodium–glucose co-transport likely permits the administration of a normal recommended or even high-protein diet, highly desirable for sarcopenic diabetic patients.
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Affiliation(s)
- Samuel N. Heyman
- Department of Medicine, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem 9765422, Israel
- Division of Geriatrics, Herzog Hospital, Jerusalem 9765422, Israel
- Correspondence:
| | - Itamar Raz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9765422, Israel
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem 9124001, Israel
| | - Jamie P. Dwyer
- Clinical and Translational Science Institute, University of Utah Health, Salt Lake City, UT 84112, USA
| | | | - Julia B. Lewis
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Departments of Medicine and Nephrology, Vanderbilt University Medical Center, Nashville, TN 37011, USA
| | - Zaid Abassi
- Department of Physiology and Biophysics, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel
- Department of Laboratory Medicine, Rambam Health Care Campus, Haifa 3109601, Israel
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21
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Mogi M, Maruhashi T, Higashi Y, Masuda T, Nagata D, Nagai M, Bokuda K, Ichihara A, Nozato Y, Toba A, Narita K, Hoshide S, Tanaka A, Node K, Yoshida Y, Shibata H, Katsurada K, Kuwabara M, Kodama T, Shinohara K, Kario K. Update on Hypertension Research in 2021. Hypertens Res 2022; 45:1276-1297. [PMID: 35790879 PMCID: PMC9255494 DOI: 10.1038/s41440-022-00967-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 12/16/2022]
Abstract
In 2021, 217 excellent manuscripts were published in Hypertension Research. Editorial teams greatly appreciate the authors' contribution to hypertension research progress. Here, our editorial members have summarized twelve topics from published work and discussed current topics in depth. We hope you enjoy our special feature, "Update on Hypertension Research in 2021".
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Affiliation(s)
- Masaki Mogi
- Department of Pharmacology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Tohon, Ehime, 791-0295, Japan.
| | - Tatsuya Maruhashi
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan
| | - Yukihito Higashi
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Michiaki Nagai
- Department of Cardiology, Hiroshima City Asa Hospital, 1-2-1 Kameyamaminami Asakita-ku, Hiroshima, 731-0293, Japan
| | - Kanako Bokuda
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Atsuhiro Ichihara
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yoichi Nozato
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ayumi Toba
- Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Sakaecho, Itabashi-ku, Tokyo, 173-0015, Japan
| | - Keisuke Narita
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-1-1, Nabeshima, Saga, 849-8501, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-1-1, Nabeshima, Saga, 849-8501, Japan
| | - Yuichi Yoshida
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, 1-1, 1-1 Idaigaoka, Hasama-machi, Yufu city, Oita, 879-5593, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, 1-1, 1-1 Idaigaoka, Hasama-machi, Yufu city, Oita, 879-5593, Japan
| | - Kenichi Katsurada
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
- Division of Clinical Pharmacology, Department of Pharmacology, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Masanari Kuwabara
- Department of Cardiology, Toranomon Hospital, 2-2-2, Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Takahide Kodama
- Department of Cardiology, Toranomon Hospital, 2-2-2, Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Keisuke Shinohara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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22
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Vallon V, Kim YC. Protecting the Kidney: The Unexpected Logic of Inhibiting a Glucose Transporter. Clin Pharmacol Ther 2022; 112:434-438. [PMID: 35689828 DOI: 10.1002/cpt.2651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/13/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Volker Vallon
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California, USA.,Department of Pharmacology, University of California San Diego, La Jolla, California, USA.,VA San Diego Healthcare System, San Diego, California, USA
| | - Young Chul Kim
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California, USA.,VA San Diego Healthcare System, San Diego, California, USA
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23
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Freedman BS. Physiology assays in human kidney organoids. Am J Physiol Renal Physiol 2022; 322:F625-F638. [PMID: 35379001 PMCID: PMC9076410 DOI: 10.1152/ajprenal.00400.2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 01/15/2023] Open
Abstract
Kidney organoids derived from human pluripotent stem cells constitute a novel model of disease, development, and regenerative therapy. Organoids are human, experimentally accessible, high throughput, and enable reconstitution of tissue-scale biology in a petri dish. Although gene expression patterns in organoid cells have been analyzed extensively, less is known about the functionality of these structures. Here, we review assays of physiological function in human kidney organoids, including best practices for quality control, and future applications. Tubular structures in organoids accumulate specific molecules through active transport, including dextran and organic anions, and swell with fluid in response to cAMP stimulation. When engrafted into animal models in vivo, organoids form vascularized glomerulus-like structures capable of size-selective filtration. Organoids exhibit metabolic, endocrine, injury, and infection phenotypes, although their specificity is not yet fully clear. To properly interpret organoid physiology assays, it is important to incorporate appropriate negative and positive controls, statistical methods, data presentation, molecular mechanisms, and clinical data sets. Improvements in organoid perfusion, patterning, and maturation are needed to enable branching morphogenesis, urine production, and renal replacement. Reconstituting renal physiology with kidney organoids is a new field with potential to provide fresh insights into classical phenomena.
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Affiliation(s)
- Benjamin S Freedman
- Division of Nephrology, Kidney Research Institute, and Institute for Stem Cell and Regenerative Medicine, Department of Medicine, Department of Laboratory Medicine and Physiology (adjunct), and Department of Bioengineering (adjunct), University of Washington School of Medicine, Seattle, Washington
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24
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Kravtsova O, Bohovyk R, Levchenko V, Palygin O, Klemens CA, Rieg T, Staruschenko A. SGLT2 inhibition effect on salt-induced hypertension, RAAS, and Na + transport in Dahl SS rats. Am J Physiol Renal Physiol 2022; 322:F692-F707. [PMID: 35466690 PMCID: PMC9142161 DOI: 10.1152/ajprenal.00053.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/08/2022] [Accepted: 04/21/2022] [Indexed: 12/27/2022] Open
Abstract
Na+-glucose cotransporter-2 (SGLT2) inhibitors are the new mainstay of treatment for diabetes mellitus and cardiovascular diseases. Despite the remarkable benefits, the molecular mechanisms mediating the effects of SGLT2 inhibitors on water and electrolyte balance are incompletely understood. The goal of this study was to determine whether SGLT2 inhibition alters blood pressure and kidney function via affecting the renin-angiotensin-aldosterone system (RAAS) and Na+ channels/transporters along the nephron in Dahl salt-sensitive rats, a model of salt-induced hypertension. Administration of dapagliflozin (Dapa) at 2 mg/kg/day via drinking water for 3 wk blunted the development of salt-induced hypertension as evidenced by lower blood pressure and a left shift of the pressure natriuresis curve. Urinary flow rate, glucose excretion, and Na+- and Cl--to-creatinine ratios increased in Dapa-treated compared with vehicle-treated rats. To define the contribution of the RAAS, we measured various hormones. Despite apparent effects on Na+- and Cl--to-creatinine ratios, Dapa treatment did not affect RAAS metabolites. Subsequently, we assessed the effects of Dapa on renal Na+ channels and transporters using RT-PCR, Western blot analysis, and patch clamp. Neither mRNA nor protein expression levels of renal transporters (SGLT2, Na+/H+ exchanger isoform 3, Na+-K+-2Cl- cotransporter 2, Na+-Cl- cotransporter, and α-, β-, and γ-epithelial Na+ channel subunits) changed significantly between groups. Furthermore, electrophysiological experiments did not reveal any difference in Dapa treatment on the conductance and activity of epithelial Na+ channels. Our data suggest that SGLT2 inhibition in a nondiabetic model of salt-sensitive hypertension blunts the development of salt-induced hypertension by causing glucosuria and natriuresis without changes in the RAAS or the expression or activity of the main Na+ channels and transporters.NEW & NOTEWORTHY The present study indicates that Na+-glucose cotransporter-2 (SGLT2) inhibition in a nondiabetic model of salt-sensitive hypertension blunts the development and magnitude of salt-induced hypertension. Chronic inhibition of SGLT2 increases glucose and Na+ excretion without secondary effects on the expression and function of other Na+ transporters and channels along the nephron and hormone levels in the renin-angiotensin-aldosterone system. These data provide novel insights into the effects of SGLT2 inhibitors and their potential use in hypertension.
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Affiliation(s)
- Olha Kravtsova
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
| | - Ruslan Bohovyk
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
| | - Vladislav Levchenko
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
| | - Oleg Palygin
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Christine A Klemens
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
- Hypertension and Kidney Research Center, University of South Florida, Tampa, Florida
| | - Timo Rieg
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
- James A. Haley Veterans' Hospital, Tampa, Florida
- Hypertension and Kidney Research Center, University of South Florida, Tampa, Florida
| | - Alexander Staruschenko
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
- James A. Haley Veterans' Hospital, Tampa, Florida
- Hypertension and Kidney Research Center, University of South Florida, Tampa, Florida
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25
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Liu R. Tubuloglomerular feedback: a key player in obesity-associated kidney injury. Am J Physiol Renal Physiol 2022; 322:F587-F588. [PMID: 35403452 PMCID: PMC9054322 DOI: 10.1152/ajprenal.00068.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 12/28/2022] Open
Affiliation(s)
- Ruisheng Liu
- Department of Molecular Pharmacology and Physiology, College of Medicine, University of South Florida, Tampa, Florida
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26
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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.
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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
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27
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Abstract
Circulating blood is filtered across the glomerular barrier to form an ultrafiltrate of plasma in the Bowman's space. The volume of glomerular filtration adjusted by time is defined as the glomerular filtration rate (GFR), and the total GFR is the sum of all single-nephron GFRs. Thus, when the single-nephron GFR is increased in the context of a normal number of functioning nephrons, single glomerular hyperfiltration results in 'absolute' hyperfiltration in the kidney. 'Absolute' hyperfiltration can occur in healthy people after high protein intake, during pregnancy and in patients with diabetes, obesity or autosomal-dominant polycystic kidney disease. When the number of functioning nephrons is reduced, single-nephron glomerular hyperfiltration can result in a GFR that is within or below the normal range. This 'relative' hyperfiltration can occur in patients with a congenitally reduced nephron number or with an acquired reduction in nephron mass consequent to surgery or kidney disease. Improved understanding of the mechanisms that underlie 'absolute' and 'relative' glomerular hyperfiltration in different clinical settings, and of whether and how the single-nephron haemodynamic and related biomechanical forces that underlie glomerular hyperfiltration promote glomerular injury, will pave the way toward the development of novel therapeutic interventions that attenuate glomerular hyperfiltration and potentially prevent or limit consequent progressive kidney injury and loss of function.
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28
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Swapnasrita S, Carlier A, Layton AT. Sex-Specific Computational Models of Kidney Function in Patients With Diabetes. Front Physiol 2022; 13:741121. [PMID: 35153824 PMCID: PMC8827383 DOI: 10.3389/fphys.2022.741121] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 01/04/2022] [Indexed: 12/25/2022] Open
Abstract
The kidney plays an essential role in homeostasis, accomplished through the regulation of pH, electrolytes and fluids, by the building blocks of the kidney, the nephrons. One of the important markers of the proper functioning of a kidney is the glomerular filtration rate. Diabetes is characterized by an enlargement of the glomerular and tubular size of the kidney, affecting the afferent and efferent arteriole resistance and hemodynamics, ultimately leading to chronic kidney disease. We postulate that the diabetes-induced changes in kidney may exhibit significant sex differences as the distribution of renal transporters along the nephron may be markedly different between women and men, as recently shown in rodents. The goals of this study are to (i) analyze how kidney function is altered in male and female patients with diabetes, and (ii) assess the renal effects, in women and men, of an anti-hyperglycemic therapy that inhibits the sodium-glucose cotransporter 2 (SGLT2) in the proximal convoluted tubules. To accomplish these goals, we have developed computational models of kidney function, separate for male and female patients with diabetes. The simulation results indicate that diabetes enhances Na+ transport, especially along the proximal tubules and thick ascending limbs, to similar extents in male and female patients, which can be explained by the diabetes-induced increase in glomerular filtration rate. Additionally, we conducted simulations to study the effects of diabetes and SGLT2 inhibition on solute and water transport along the nephrons. Model simulations also suggest that SGLT2 inhibition raises luminal [Cl–] at the macula densa, twice as much in males as in females, and could indicate activation of the tubuloglomerular feedback signal. By inducing osmotic diuresis in the proximal tubules, SGLT2 inhibition reduces paracellular transport, eventually leading to diuresis and natriuresis. Those effects on urinary excretion are blunted in women, in part due to their higher distal transport capacity.
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Affiliation(s)
- Sangita Swapnasrita
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, Netherlands
| | - Aurélie Carlier
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, Netherlands
| | - Anita T Layton
- Department of Applied Mathematics, University of Waterloo, Waterloo, ON, Canada.,Department of Biology, Cheriton School of Computer Science, School of Pharmacology, University of Waterloo, Waterloo, ON, Canada
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29
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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.
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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
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30
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Vallon V, Nakagawa T. Renal Tubular Handling of Glucose and Fructose in Health and Disease. Compr Physiol 2021; 12:2995-3044. [PMID: 34964123 PMCID: PMC9832976 DOI: 10.1002/cphy.c210030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The proximal tubule of the kidney is programmed to reabsorb all filtered glucose and fructose. Glucose is taken up by apical sodium-glucose cotransporters SGLT2 and SGLT1 whereas SGLT5 and potentially SGLT4 and GLUT5 have been implicated in apical fructose uptake. The glucose taken up by the proximal tubule is typically not metabolized but leaves via the basolateral facilitative glucose transporter GLUT2 and is returned to the systemic circulation or used as an energy source by distal tubular segments after basolateral uptake via GLUT1. The proximal tubule generates new glucose in metabolic acidosis and the postabsorptive phase, and fructose serves as an important substrate. In fact, under physiological conditions and intake, fructose taken up by proximal tubules is primarily utilized for gluconeogenesis. In the diabetic kidney, glucose is retained and gluconeogenesis enhanced, the latter in part driven by fructose. This is maladaptive as it sustains hyperglycemia. Moreover, renal glucose retention is coupled to sodium retention through SGLT2 and SGLT1, which induces secondary deleterious effects. SGLT2 inhibitors are new anti-hyperglycemic drugs that can protect the kidneys and heart from failing independent of kidney function and diabetes. Dietary excess of fructose also induces tubular injury. This can be magnified by kidney formation of fructose under pathological conditions. Fructose metabolism is linked to urate formation, which partially accounts for fructose-induced tubular injury, inflammation, and hemodynamic alterations. Fructose metabolism favors glycolysis over mitochondrial respiration as urate suppresses aconitase in the tricarboxylic acid cycle, and has been linked to potentially detrimental aerobic glycolysis (Warburg effect). © 2022 American Physiological Society. Compr Physiol 12:2995-3044, 2022.
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Affiliation(s)
- Volker Vallon
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California, USA,Department of Pharmacology, University of California San Diego, La Jolla, California, USA,VA San Diego Healthcare System, San Diego, California, USA,Correspondence to and
| | - Takahiko Nakagawa
- Division of Nephrology, Rakuwakai-Otowa Hospital, Kyoto, Japan,Correspondence to and
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31
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Tauber P, Sinha F, Berger RS, Gronwald W, Dettmer K, Kuhn M, Trum M, Maier LS, Wagner S, Schweda F. Empagliflozin Reduces Renal Hyperfiltration in Response to Uninephrectomy, but Is Not Nephroprotective in UNx/DOCA/Salt Mouse Models. Front Pharmacol 2021; 12:761855. [PMID: 34992532 PMCID: PMC8724563 DOI: 10.3389/fphar.2021.761855] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 12/06/2021] [Indexed: 12/20/2022] Open
Abstract
Large-scale clinical outcome studies demonstrated the efficacy of SGLT2 inhibitors in patients with type II diabetes. Besides their therapeutic efficacy in diabetes, significant renoprotection was observed in non-diabetic patients with chronic kidney disease (CKD), suggesting the existence of glucose-independent beneficial effects of SGLT2 inhibitors. However, the relevant mechanisms by which SGLT2 inhibition delays the progression of renal injury are still largely unknown and speculative. Previous studies showed that SGLT2 inhibitors reduce diabetic hyperfiltration, which is likely a key element in renoprotection. In line with this hypothesis, this study aimed to investigate the nephroprotective effects of the SGLT2 inhibitor empagliflozin (EMPA) in different mouse models with non-diabetic hyperfiltration and progressing CKD to identify the underlying diabetes-independent cellular mechanisms. Non-diabetic hyperfiltration was induced by unilateral nephrectomy (UNx). Since UNx alone does not result in renal damage, renal disease models with varying degrees of glomerular damage and albuminuria were generated by combining UNx with high NaCl diets ± deoxycorticosterone acetate (DOCA) in different mouse strains with and without genetic predisposition for glomerular injury. Renal parameters (GFR, albuminuria, urine volume) were monitored for 4–6 weeks. Application of EMPA via the drinking water resulted in sufficient EMPA plasma concentration and caused glucosuria, diuresis and in some models renal hypertrophy. EMPA had no effect on GFR in untreated wildtype animals, but significantly reduced hyperfiltration after UNx by 36%. In contrast, EMPA did not reduce UNx induced hyperfiltration in any of our kidney disease models, regardless of their degree of glomerular damage caused by DOCA/salt treatment. Consistent with the lack of reduction in glomerular hyperfiltration, EMPA-treated animals developed albuminuria and renal fibrosis to a similar extent as H2O control animals. Taken together, the data clearly indicate that blockade of SGLT2 has the potential to reduce non-diabetic hyperfiltration in otherwise untreated mice. However, no effects on hyperfiltration or progression of renal injury were observed in hypervolemic kidney disease models, suggesting that high salt intake and extracellular volume might attenuate the protective effects of SGLT2 blockers.
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Affiliation(s)
- Philipp Tauber
- Institute of Physiology, University of Regensburg, Regensburg, Germany
- *Correspondence: Philipp Tauber,
| | - Frederick Sinha
- Institute of Physiology, University of Regensburg, Regensburg, Germany
| | - Raffaela S. Berger
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Wolfram Gronwald
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Katja Dettmer
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Michaela Kuhn
- Institute of Physiology, University of Würzburg, Würzburg, Germany
| | - Maximilian Trum
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Lars S. Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Stefan Wagner
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Frank Schweda
- Institute of Physiology, University of Regensburg, Regensburg, Germany
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32
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A Role for SGLT-2 Inhibitors in Treating Non-diabetic Chronic Kidney Disease. Drugs 2021; 81:1491-1511. [PMID: 34363606 DOI: 10.1007/s40265-021-01573-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 02/06/2023]
Abstract
In recent years, inhibitors of the sodium-glucose co-transporter 2 (SGLT2 inhibitors) have been shown to have significant protective effects on the kidney and the cardiovascular system in patients with diabetes. This effect is also manifested in chronic kidney disease (CKD) patients and is minimally due to improved glycaemic control. Starting from these positive findings, SGLT2 inhibitors have also been tested in patients with non-diabetic CKD or heart failure with reduced ejection fraction. Recently, the DAPA-CKD trial showed a significantly lower risk of CKD progression or death from renal or cardiovascular causes in a mixed population of patients with diabetic and non-diabetic CKD receiving dapagliflozin in comparison with placebo. In patients with heart failure and reduced ejection fraction, two trials (EMPEROR-Reduced and DAPA-HF) also found a significantly lower risk of reaching the secondary renal endpoint in those treated with an SGLT2 inhibitor in comparison with placebo. This also applied to patients with CKD. Apart from their direct mechanism of action, SGLT2 inhibitors have additional effects that could be of particular interest for patients with non-diabetic CKD. Among these, SGLT2 inhibitors reduce blood pressure and serum acid uric levels and can increase hemoglobin levels. Some safety issues should be further explored in the CKD population. SGLT2 inhibitors can minimally increase potassium levels, but this has not been shown by the CREDENCE trial. They also increase magnesium and phosphate reabsorption. These effects could become more significant in patients with advanced CKD and will need monitoring when these agents are used more extensively in the CKD population. Conversely, they do not seem to increase the risk of acute kidney injury.
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Hu R, Layton A. A Computational Model of Kidney Function in a Patient with Diabetes. Int J Mol Sci 2021; 22:5819. [PMID: 34072329 PMCID: PMC8198657 DOI: 10.3390/ijms22115819] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/12/2021] [Accepted: 05/27/2021] [Indexed: 12/24/2022] Open
Abstract
At the onset of diabetes, the kidney grows large and the glomerular filtration rate becomes abnormally high. These structural and hemodynamics changes affect kidney function and may contribute to the development of chronic kidney disease. The goal of this study is to analyze how kidney function is altered in patients with diabetes and the renal effects of an anti-hyperglyceamic therapy that inhibits the sodium-glucose cotransporter 2 (SGLT2) in the proximal convoluted tubules. To accomplish that goal, we have developed a computational model of kidney function in a patient with diabetes and conducted simulations to study the effects of diabetes and SGLT2 inhibition on solute and water transport along the nephrons. Simulation results indicate that diabetes-induced hyperfiltration and tubular hypertrophy enhances Na+ transport, especially along the proximal tubules and thick ascending limbs. These simulations suggest that SGLT2 inhibition may attenuate glomerular hyperfiltration by limiting Na+-glucose transport, raising luminal [Cl-] at the macula densa, restoring the tubuloglomerular feedback signal, thereby reducing single-nephron glomerular filtration rate.
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Affiliation(s)
- Rui Hu
- Department of Applied Mathematics, University of Waterloo, Waterloo, ON N2L 3G1, Canada;
| | - Anita Layton
- Department of Applied Mathematics, University of Waterloo, Waterloo, ON N2L 3G1, Canada;
- Department of Biology, Cheriton School of Computer Science, and School of Pharmacology, University of Waterloo, Waterloo, ON N2L 3G1, Canada
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Affiliation(s)
- David H Ellison
- Department of Medicine and Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, Oregon.,Veterans Affairs Portland Health Care System, Portland, Oregon
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Duan S, Lu F, Song D, Zhang C, Zhang B, Xing C, Yuan Y. Current Challenges and Future Perspectives of Renal Tubular Dysfunction in Diabetic Kidney Disease. Front Endocrinol (Lausanne) 2021; 12:661185. [PMID: 34177803 PMCID: PMC8223745 DOI: 10.3389/fendo.2021.661185] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/21/2021] [Indexed: 12/29/2022] Open
Abstract
Over decades, substantial progress has been achieved in understanding the pathogenesis of proteinuria in diabetic kidney disease (DKD), biomarkers for DKD screening, diagnosis, and prognosis, as well as novel hypoglycemia agents in clinical trials, thereby rendering more attention focused on the role of renal tubules in DKD. Previous studies have demonstrated that morphological and functional changes in renal tubules are highly involved in the occurrence and development of DKD. Novel tubular biomarkers have shown some clinical importance. However, there are many challenges to transition into personalized diagnosis and guidance for individual therapy in clinical practice. Large-scale clinical trials suggested the clinical relevance of increased proximal reabsorption and hyperfiltration by sodium-glucose cotransporter-2 (SGLT2) to improve renal outcomes in patients with diabetes, further promoting the emergence of renal tubulocentric research. Therefore, this review summarized the recent progress in the pathophysiology associated with involved mechanisms of renal tubules, potential tubular biomarkers with clinical application, and renal tubular factors in DKD management. The mechanism of kidney protection and impressive results from clinical trials of SGLT2 inhibitors were summarized and discussed, offering a comprehensive update on therapeutic strategies targeting renal tubules.
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