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van Raalte DH, Bjornstad P, Cherney DZI, de Boer IH, Fioretto P, Gordin D, Persson F, Rosas SE, Rossing P, Schaub JA, Tuttle K, Waikar SS, Heerspink HJL. Combination therapy for kidney disease in people with diabetes mellitus. Nat Rev Nephrol 2024:10.1038/s41581-024-00827-z. [PMID: 38570632 DOI: 10.1038/s41581-024-00827-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/05/2024]
Abstract
Diabetic kidney disease (DKD), defined as co-existing diabetes and chronic kidney disease in the absence of other clear causes of kidney injury, occurs in approximately 20-40% of patients with diabetes mellitus. As the global prevalence of diabetes has increased, DKD has become highly prevalent and a leading cause of kidney failure, accelerated cardiovascular disease, premature mortality and global health care expenditure. Multiple pathophysiological mechanisms contribute to DKD, and single lifestyle or pharmacological interventions have shown limited efficacy at preserving kidney function. For nearly two decades, renin-angiotensin system inhibitors were the only available kidney-protective drugs. However, several new drug classes, including sodium glucose cotransporter-2 inhibitors, a non-steroidal mineralocorticoid antagonist and a selective endothelin receptor antagonist, have now been demonstrated to improve kidney outcomes in people with type 2 diabetes mellitus. In addition, emerging preclinical and clinical evidence of the kidney-protective effects of glucagon-like-peptide-1 receptor agonists has led to the prospective testing of these agents for DKD. Research and clinical efforts are geared towards using therapies with potentially complementary efficacy in combination to safely halt kidney disease progression. As more kidney-protective drugs become available, the outlook for people living with DKD should improve in the next few decades.
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Affiliation(s)
- Daniël H van Raalte
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, VUMC, Amsterdam, The Netherlands.
- Diabetes Center, Amsterdam University Medical Centers, VUMC, Amsterdam, The Netherlands.
- Research Institute for Cardiovascular Sciences, VU University, Amsterdam, The Netherlands.
| | - Petter Bjornstad
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ian H de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Paola Fioretto
- Department of Medicine, University of Padua, Unit of Medical Clinic 3, Padua, Italy
| | - Daniel Gordin
- Minerva Foundation Institute for Medical Research, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Sylvia E Rosas
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jennifer A Schaub
- Nephrology Division, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Katherine Tuttle
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Spokane and Seattle, Washington, USA
- Nephrology Division, Kidney Research Institute and Institute of Translational Health Sciences, University of Washington, Spokane and Seattle, Washington, USA
| | - Sushrut S Waikar
- Section of Nephrology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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Karakasis P, Popovic DS, Patoulias D, Koufakis T, Papanas N, Fragakis N, Rizzo M. The Effect of Sodium-Glucose Cotransporter Inhibitors on Renal Function as Adjunctive to Insulin in Adults with Type 1 Diabetes: An Updated Multilevel Meta-analysis of Randomized Controlled Trials. Diabetes Ther 2024; 15:521-532. [PMID: 38180713 PMCID: PMC10838855 DOI: 10.1007/s13300-023-01523-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/14/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION This systematic review aimed to summarize the existing evidence from published randomized controlled trials (RCTs) on the impact of sodium-glucose cotransporter (SGLT) inhibitors on albuminuria levels and renal function in patients with type 1 diabetes mellitus (T1D). METHODS The literature search was performed through Medline (via PubMed), Cochrane Library, and Scopus until November 11, 2023. Double-independent study selection, data extraction, and quality assessment were performed. Evidence was pooled with three-level mixed-effects meta-analysis. RESULTS In total, 5221 participants with T1D among 11 RCTs were analyzed. All RCTs had low risk of bias according to the Cochrane Collaboration tool (RoB 2). SGLT inhibitors were associated with a significantly greater reduction in urine albumin-to-creatinine ratio (UACR) compared to controls (MD = - 23.13%; 95% CI = [- 33.69, - 12.57]; P < 0.001; level of evidence high). On the basis of subgroup analysis, this effect was consistent across all available SGLT inhibitors, irrespective of the dosage. Finally, a neutral class effect was observed on the estimated glomerular filtration rate (eGFR, MD = - 1.03 mL/min/1.73 m2; 95% CI = [- 2.26, 0.19]; P = 0.1; level of evidence moderate). Only empagliflozin was associated with a significant reduction in eGFR compared to placebo (MD = - 2.23 mL/min/1.73 m2; 95% CI = [- 3.62, - 0.84]; P = 0.002). CONCLUSION Our findings suggest that adjunctive therapy with SGLT inhibitors results in a significant reduction in albuminuria, while their use is associated with a neutral effect on creatinine clearance, as a measure of renal function. Future renal outcome trials are needed to assess SGLT inhibitors' role in the pharmacological armamentarium against diabetic nephropathy in T1D.
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Affiliation(s)
- Paschalis Karakasis
- Second Cardiology Department, Hippokration General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Aristotle University of Thessaloniki, General Hospital "Hippokration", Thessaloniki, Greece
| | - Theocharis Koufakis
- Second Propaedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Nikolaos Fragakis
- Second Cardiology Department, Hippokration General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Manfredi Rizzo
- School of Medicine, Mohammed Bin Rashid University, Dubai, United Arab Emirates
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, School of Medicine, University of Palermo, Palermo, Italy
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Popovic DS, Patoulias D, Gnudi L, Mantzoros CS. Diabetic kidney disease in type 1 diabetes: challenges and differences from type 2 diabetes. Metabolism 2024; 151:155763. [PMID: 38122894 DOI: 10.1016/j.metabol.2023.155763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, General Hospital Hippokration, Thessaloniki, Greece
| | - Luigi Gnudi
- School of Cardiovascular and Metabolic Medicine & Science, Kings College London, Department of Diabetes and Endocrinology, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Christos S Mantzoros
- Beth Israel Deaconess Medical Center and Boston VA Healthcare System, Harvard Medical School, Boston, MA, USA.
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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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Sridhar VS, Limonte CP, Groop PH, Heerspink HJL, Pratley RE, Rossing P, Skyler JS, Cherney DZI. Chronic kidney disease in type 1 diabetes: translation of novel type 2 diabetes therapeutics to individuals with type 1 diabetes. Diabetologia 2024; 67:3-18. [PMID: 37801140 DOI: 10.1007/s00125-023-06015-1] [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: 04/26/2023] [Accepted: 07/21/2023] [Indexed: 10/07/2023]
Abstract
Current management of chronic kidney disease (CKD) in type 1 diabetes centres on glycaemic control, renin-angiotensin system inhibition and optimisation of risk factors including blood pressure, lipids and body weight. While these therapeutic approaches have significantly improved outcomes among people with type 1 diabetes and CKD, this population remains at substantial elevated risk for adverse kidney and cardiovascular events, with limited improvements over the last few decades. The significant burden of CKD and CVD in type 1 diabetes populations highlights the need to identify novel therapies with the potential for heart and kidney protection. Over the last decade, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists have emerged as potent kidney-protective and/or cardioprotective agents in type 2 diabetes. The consistent, substantial kidney and cardiovascular benefits of these agents has led to their incorporation into professional guidelines as foundational care for type 2 diabetes. Furthermore, introduction of these agents into clinical practice has been accompanied by a shift in the focus of diabetes care from a 'glucose-centric' to a 'cardiorenal risk-centric' approach. In this review, we evaluate the potential translation of novel type 2 diabetes therapeutics to individuals with type 1 diabetes with the lens of preventing the development and progression of CKD.
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Affiliation(s)
- Vikas S Sridhar
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada.
| | - Christine P Limonte
- Division of Nephrology, University of Washington, Seattle, WA, USA
- Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- The George Institute for Global Health, Sydney, Australia
| | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jay S Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David Z I Cherney
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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Scarr D, Lovblom E, Ye H, Liu H, Bakhsh A, Verhoeff NJ, Wolever TMS, Lawler PR, Sharma K, Cherney DZI, Perkins BA. Ketone production and excretion even during mild hyperglycemia and the impact of sodium-glucose co-transporter inhibition in type 1 diabetes. Diabetes Res Clin Pract 2024; 207:111031. [PMID: 38036220 DOI: 10.1016/j.diabres.2023.111031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/18/2023] [Accepted: 11/26/2023] [Indexed: 12/02/2023]
Abstract
AIMS We aimed to determine if ketone production and excretion are increased even at mild fasting hyperglycemia in type 1 diabetes (T1D) and if these are modified by ketoacidosis risk factors, including sodium-glucose co-transporter inhibition (SGLTi) and female sex. METHODS In secondary analysis of an 8-week single-arm open-label trial of empagliflozin (NCT01392560) we evaluated ketone concentrations during extended fasting and clamped euglycemia (4-6 mmol/L) and mild hyperglycemia (9-11 mmol/L) prior to and after treatment. Plasma and urine beta-hydroxybutyrate (BHB) concentrations and fractional excretion were analyzed by metabolomic analysis. RESULTS Forty participants (50 % female), aged 24 ± 5 years, HbA1c 8.0 ± 0.9 % (64 ± 0.08 mmol/mol) with T1D duration of 17.5 ± 7 years, were studied. Increased BHB production even during mild hyperglycemia (median urine 6.3[3.5-13.6] vs. 3.5[2.2-7.0] µmol/mmol creatinine during euglycemia, p < 0.001) was compensated by increased fractional excretion (0.9 % [0.3-1.6] vs. 0.4 % [0.2-0.9], p < 0.001). SGLTi increased production and attenuated the increased BHB fractional excretion (decreased to 0.3 % during mild hyperglycemia, p < 0.001), resulting in higher plasma concentrations (increased to 0.21 [0.05-0.40] mmol/L, p < 0.001), particularly in females (interaction p < 0.001). CONCLUSIONS Even mild hyperglycemia is associated with greater ketone production, compensated by urinary excretion, in T1D. However, SGLTi exaggerates production and partially reduces compensatory excretion, particularly in women.
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Affiliation(s)
- Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Hongping Ye
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Hongyan Liu
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Abdulmohsen Bakhsh
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Kidney & Pancreas Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Natasha J Verhoeff
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Thomas M S Wolever
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Canada; The Peter Munk Cardiac Centre at University Health Network, University of Toronto, Canada
| | - Kumar Sharma
- Center for Renal Precision Medicine, Division of Nephrology, Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Durán-Martínez M, Azriel S, Doulatram-Gamgaram VK, Moreno-Pérez Ó, Pinés-Corrales PJ, Tejera-Pérez C, Merino-Torres JF, Brito-Sanfiel M, Chico A, Marco A, García-Fernández E, Martínez-Montoro JI. Real-world safety and effectiveness of dapagliflozin in people living with type 1 diabetes in Spain: The Dapa-ON multicenter retrospective study. DIABETES & METABOLISM 2024; 50:101501. [PMID: 38061425 DOI: 10.1016/j.diabet.2023.101501] [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: 09/26/2023] [Revised: 11/06/2023] [Accepted: 11/24/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE To assess real-world safety and effectiveness of dapagliflozin in people living with type 1 diabetes mellitus (T1DM). METHODS We conducted a multicenter retrospective study in Spain including data from 250 people living with T1DM receiving dapagliflozin as add-on therapy to insulin (80.8 % on-label use). The number of diabetic ketoacidosis (DKA) events was calculated over a 12-month follow-up (primary outcome). Changes in body weight, HbA1c, total daily insulin dose, and continuous glucose monitoring (CGM) metrics from baseline (at dapagliflozin prescription) to 12 months were also evaluated. RESULTS A total of five DKA events (2.4 % [95 % CI 0.3;4.5] were reported in patients with a 12-month follow-up, n = 207): two events related to insulin pump malfunction, two events related to concomitant illnesses, and one event related to insulin dose omission. DKA events were more frequent among insulin pump users than among participants on multiple daily injections (7.7 % versus 1.2 %). Four of the reported DKA events occurred within the first six months after initiation of dapagliflozin. No deaths or persistent sequelae due to DKA were reported. No severe hypoglycemia episodes were reported. Significant reductions in mean body weight (-3.3 kg), HbA1c (-0.6 %), and total daily insulin dose (-8.6 %), P < 0.001, were observed 12 months after dapagliflozin prescription. Significant improvements in TIR (+9.3 %), TAR (-7.2 %), TBR (-2.5 %), and coefficient of variation (-5.1 %), P < 0.001, were also observed in the subgroup of patients with available CGM data. Finally, an improvement in urinary albumin-to-creatinine ratio (UACR) was found among participants with UACR ≥ 30 mg/g at baseline (median decrease of 99 mg/g in UACR, P = 0.001). CONCLUSION The use of dapagliflozin in people living with T1DM has an appropriate safety profile after careful selection of participants and implementation of strategies to reduce the risk of DKA (i.e., prescribed according to the recommendations of the European Medicines Agency), and also leads to clinical improvements in this population.
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Affiliation(s)
- María Durán-Martínez
- Department of Endocrinology and Nutrition, Getafe University Hospital, Madrid, Spain; Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Spain
| | - Sharona Azriel
- Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Spain; Department of Endocrinology and Nutrition, Infanta Sofia University Hospital, Madrid, Spain
| | - Viyey Kishore Doulatram-Gamgaram
- Department of Endocrinology and Nutrition, Regional University Hospital of Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
| | - Óscar Moreno-Pérez
- Endocrinology and Nutrition Department, Dr. Balmis General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain; Clinical Medicine Department, Miguel Hernández University, Elche, Alicante, Spain
| | - Pedro J Pinés-Corrales
- Department of Endocrinology and Nutrition, Albacete University Hospital, Albacete, Spain
| | - Cristina Tejera-Pérez
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Ferrol (CHUF/SERGAS), A Coruña, Spain; Epigenomics in Endocrinology and Nutrition Group, Epigenomics Unit, Instituto de Investigacion Sanitaria de Santiago de Compostela (IDIS), Complejo Hospitalario Universitario de Santiago de Compostela (CHUS/SERGAS), Santiago de Compostela, Spain
| | - Juan Francisco Merino-Torres
- Department of Endocrinology and Nutrition, University and Polytechnic Hospital La Fe, Valencia, Spain; Joint Research Unit On Endocrinology, Nutrition and Clinical Dietetics, University of Valencia-Health Research Institute La Fe, Valencia, Spain; Medicine Department, Universitat de València, Valencia, Spain
| | - Miguel Brito-Sanfiel
- Department of Endocrinology and Nutrition, Puerta de Hierro University Hospital, Madrid, Spain
| | - Ana Chico
- Department of Endocrinology and Nutrition, Hospital Santa Creu i Sant Pau, Barcelona, Spain; CIBER-BBN, Instituto de Salud Carlos III, Madrid, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Amparo Marco
- Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Spain; Department of Endocrinology and Nutrition, Toledo University Hospital, Toledo, Spain
| | - Elena García-Fernández
- Department of Endocrinology and Nutrition, 12 de Octubre University Hospital, Madrid, Spain
| | - José Ignacio Martínez-Montoro
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain; Faculty of Medicine, University of Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de la Fisiopatología de la Obesidad y la Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain.
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Papaetis GS. SGLT2 inhibitors, intrarenal hypoxia and the diabetic kidney: insights into pathophysiological concepts and current evidence. Arch Med Sci Atheroscler Dis 2023; 8:e155-e168. [PMID: 38283924 PMCID: PMC10811536 DOI: 10.5114/amsad/176658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/08/2023] [Indexed: 01/30/2024] Open
Abstract
Approximately 20-40% of all diabetic patients experience chronic kidney disease, which is related to higher mortality (cardiovascular and all-cause). A large body of evidence suggests that renal hypoxia is one of the main forces that drives diabetic kidney disease, both in its early and advanced stages. It promotes inflammation, generation of intrarenal collagen, capillary rarefaction and eventually accumulation of extracellular matrix that destroys normal renal architecture. SGLT2 inhibitors are unquestionably a practice-changing drug class and a valuable weapon for patients with type 2 diabetes and chronic kidney disease. They have achieved several beneficial kidney effects after targeting multiple and interrelated signaling pathways, including renal hypoxia, independent of their antihyperglycemic activities. This manuscript discusses the pathophysiological concepts that underly their possible effects on modulating renal hypoxia. It also comprehensively investigates both preclinical and clinical studies that explored the possible role of SGLT2 inhibitors in this setting, so as to achieve long-term renoprotective benefits.
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Affiliation(s)
- Georgios S. Papaetis
- K.M.P THERAPIS Paphos Medical Center, Internal Medicine and Diabetes Clinic, Paphos, Cyprus
- CDA College, Paphos, Cyprus
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Hironaka J, Okada H, Hamaguchi M, Sakai K, Minamida M, Kondo Y, Hashimoto Y, Kitagawa N, Yano M, Yamazaki M, Hasegawa G, Horiguchi G, Teramukai S, Fukui M. Effects of dapagliflozin on renal function in type 1 diabetes patients in the real world: a retrospective multicenter study of the KAMOGAWA-A cohort. Diabetes Res Clin Pract 2023; 202:110794. [PMID: 37336391 DOI: 10.1016/j.diabres.2023.110794] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/21/2023]
Abstract
AIMS This study aimed to investigate the effects of dapagliflozin on renal function of type 1 diabetes patients. METHODS This retrospective multicenter cohort study enrolled 295 type 1 diabetes patients. The primary outcome was defined as the change in the estimated glomerular filtration rate (eGFR) after 24 months of dapagliflozin treatment. The secondary outcomes were defined as the changes in HbA1c, daily insulin dosage, and urinary albumin-to-creatinine ratio (UACR) after 24 months. RESULTS Finally, 255 patients were included in the final analysis (dapagliflozin group; 76 patients, non-use group; 179 patients), with a median eGFR of 74.0 mL/min/1.73m2. A 1:1 propensity score matching was performed, and 142 patients were analyzed in a linear mixed model. The least squares mean change in eGFR in the dapagliflozin group was -3.14 mL/min/1.73 m2 (95% CI: -5.62 to -0.66), a significantly smaller decrease than in the non-use group (-6.94 mL/min/1.73 m2 (95% CI: -9.39 to -4.50)) (p = 0.032). HbA1c level, total insulin dose, and UACR change were significantly lower in the dapagliflozin group than in the non-use group. CONCLUSIONS At 24 months, the decline in eGFR was significantly lower in the dapagliflozin group than in the non-use group without increasing diabetic ketoacidosis and hypoglycemia.
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Affiliation(s)
- Junya Hironaka
- Department of b, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Hiroshi Okada
- Department of b, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan.
| | - Masahide Hamaguchi
- Department of b, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan.
| | - Kimiko Sakai
- Department of Metabolism and Immunology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Megumi Minamida
- Department of b, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Yuriko Kondo
- Department of b, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Yoshitaka Hashimoto
- Department of Diabetes and Endocrinology, Matsushita Memorial Hospital, Moriguchi, Japan
| | | | - Miho Yano
- Department of Diabetology, Nishijin Hospital, Kyoto, Japan
| | - Masahiro Yamazaki
- Department of Metabolism and Immunology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Goji Hasegawa
- Department of Metabolism and Immunology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Go Horiguchi
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Michiaki Fukui
- Department of b, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
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Curovic VR, Jongs N, Kroonen MY, Zobel EH, Hansen TW, Sen T, Laverman GD, Kooy A, Persson F, Rossing P, Heerspink HJ. Optimization of Albuminuria-Lowering Treatment in Diabetes by Crossover Rotation to Four Different Drug Classes: A Randomized Crossover Trial. Diabetes Care 2023; 46:593-601. [PMID: 36657986 PMCID: PMC10020026 DOI: 10.2337/dc22-1699] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/12/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Renin-angiotensin system (RAS) inhibitors decrease the urinary albumin to creatinine ratio (UACR) but are ineffective in up to 40% of patients. We hypothesized that rotation through different drug classes overcomes RAS inhibitor resistance and tested this in a randomized crossover trial. RESEARCH DESIGN AND METHODS We assigned 26 adults with type 1 diabetes and 37 with type 2 diabetes and UACR between 30 and 500 mg/g and estimated glomerular filtration rate >45 mL/min/1.73 m2 to 4-week treatment periods with telmisartan 80 mg, empagliflozin 10 mg, linagliptin 5 mg, and baricitinib 2 mg in random order, separated by 4-week washout periods. Each participant was then re-exposed for 4 weeks to the drug that induced that individual's largest UACR reduction. Primary outcome was the difference in UACR response to the best-performing drug during the confirmation period versus UACR response to the other three drugs. RESULTS There was substantial variation in the best-performing drug. Telmisartan was best performing for 33 participants (52%), empagliflozin and linagliptin in 11 (17%), and baricitinib in 8 participants (13%). The individuals' best-performing drug changed UACR from baseline during the first and confirmatory exposures by a mean of -39.6% (95% CI -44.8, -33.8; P < 0.001) and -22.4% (95% CI -29.7, -12.5; P < 0.001), respectively. The Pearson correlation for first versus confirmatory exposure was 0.39 (P = 0.017). The mean change in UACR with the other three drugs was +1.6% (95% CI -4.3%, 8.0%; P = 0.593 versus baseline; difference versus individuals' best-performing drug at confirmation, 30.9% [95% CI 18.0, 45.3]; P < 0.001). CONCLUSIONS We demonstrated a large and reproducible variation in participants' responses to different UACR-lowering drug classes. These data support systematic rotation through different drug classes to overcome therapy resistance to RAS inhibition.
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Affiliation(s)
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Marjolein Y.A.M. Kroonen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | | | | | - Taha Sen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | | | - Adriaan Kooy
- Bethesda Diabetes Research Center, Hoogeveen, the Netherlands
- Department of Internal Medicine, University of Groningen, Groningen, the Netherlands
| | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen Denmark
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
- Corresponding author: H.J.L. Heerspink,
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Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) were originally developed as antidiabetic agents, with cardiovascular (CV) outcome trials demonstrating improved CV outcomes in patients with type 2 diabetes mellitus (T2D). Secondary analyses of CV outcome trials and later dedicated kidney outcome trials consistently reported improved kidney-related outcomes independent of T2D status and across a range of kidney function and albuminuria. Importantly, SGLT2 inhibitors are generally safe and well tolerated, with clinical trials and real-world analyses demonstrating a decrease in the risk of acute kidney injury. The kidney protective effects of SGLT2 inhibitors generally extend across different members of the class, possibly on the basis of hemodynamic, metabolic, anti-inflammatory, and antifibrotic mechanisms. In this review, we summarize the effects of SGLT2 inhibitors on kidney outcomes in diverse patient populations.
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Affiliation(s)
- Atit Dharia
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Abid Khan
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vikas S Sridhar
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada; , , , .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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12
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Stougaard EB, Kristensen PL, Kielgast U, Andersen HU, Hamid Y, Gæde PH, Søndergaard E, Dørflinger GH, Fjeldborg KK, Hansen KW, Thomsen HH, Al-Imar TMJ, Røder M, Sridhar VS, Cherney D, Rossing P, Persson F. Real life evaluation of sodium-glucose cotransporter 2 inhibition in type 1 diabetes and the risk of diabetic ketoacidosis. Diab Vasc Dis Res 2022; 19:14791641221130043. [PMID: 36262089 PMCID: PMC9585567 DOI: 10.1177/14791641221130043] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The indication for treatment of type 1 diabetes(T1D) with the sodium-glucose cotransporter 2 inhibitor (SGLT2i) dapagliflozin has been withdrawn in Europe likely because of concern for diabetic ketoacidosis (DKA). We calculated the incidence of DKA in people with T1D treated with SGLT2i in Denmark. METHODS Clinical data from adults with T1D in Denmark were collected from nine outpatient clinics. Electronic health records made the search for DKA accurate. RESULTS From a population of 10.500 we observed 134 people treated with SGLT2i over a total period of 222 patient-years. Of those 72% were female, mean age (SD) was 51.4 (13.6) years and median duration of treatment (median, IQR) with an SGLT2i were 12.0 (6.0-29.0) months. The incidence of DKA was zero%. CONCLUSION In 134 people with T1D treated with SGLT2i we found that none of the participants developed DKA during the treatment.
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Affiliation(s)
| | - Peter L Kristensen
- Department of Clinical Medicine, University of Copenhagen, Capital Region, Denmark
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Denmark
| | - Urd Kielgast
- Department of Medicine, Section of Endocrinology, 60170Zealand University Hospital, Region Zealand, Denmark
| | | | - Yasmin Hamid
- 53138Steno Diabetes Center Copenhagen, Capital Region, Denmark
| | - Peter H Gæde
- University of Southern Denmark, Institute for Regional Health, Odense, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Herlev, Denmark
| | - Esben Søndergaard
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Herlev, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Gry H Dørflinger
- Department of Internal Medicine, DNV-Gødstrup, Central Denmark Region, Denmark
- Department of Clinical Medicine, University of Aarhus, Aarhus, Denmark
| | - Karen K Fjeldborg
- Department of Endocrinology, Randers Hospital, Region Central Denmark, Denmark
| | - Klavs W Hansen
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Henrik H Thomsen
- Department of Internal Medicine, 53165Viborg Regional Hospital, Central Denmark Region, Denmark
| | - Thuraya M J Al-Imar
- Steno Diabetes Center Zealand, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | - Michael Røder
- Steno Diabetes Center Odense, University of Southern Denmark, Odense, Denmark
| | - Vikas S Sridhar
- Department of Medicine, University of Toronto, Division of Nephrology and Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - David Cherney
- Department of Medicine, University of Toronto, Division of Nephrology and Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Peter Rossing
- 53138Steno Diabetes Center Copenhagen, Capital Region, Denmark
- Department of Clinical Medicine, University of Copenhagen, Capital Region, Denmark
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13
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Stougaard EB, Rossing P, Cherney D, Vistisen D, Persson F. Sodium-glucose cotransporter 2 inhibitors as adjunct therapy for type 1 diabetes and the benefit on cardiovascular and renal disease evaluated by Steno risk engines. J Diabetes Complications 2022; 36:108257. [PMID: 35840519 DOI: 10.1016/j.jdiacomp.2022.108257] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/28/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022]
Abstract
AIMS Sodium-glucose cotransporter inhibitors (SGLTi) have beneficial cardiovascular and renal effects in persons with type 2 diabetes. No studies have shown whether this can be demonstrated in type 1 diabetes (T1D). We aimed to estimate the risk of cardiovascular disease (CVD) and end-stage kidney disease (ESKD) in persons with T1D with and without treatment with SGLTi. METHODS The study is based on 3660 adults with T1D. The Steno Type 1 Risk Engines were used to calculate 5-year risks of ESKD and 5- and 10-year risk of CVD. The effect of SGLTi was simulated by changing the HbA1c and systolic blood pressure values in accordance with results from the DEPICT studies with mean (standard deviation (SD)) of -3.6 (0.9) mmol/mol (-2.5 % (2.2)) and -1.12 (2.8) mmHg. eGFR and albuminuria were changed in accordance with results from the Tandem studies; no change in eGFR and mean (SD) %-change in albuminuria of -23.7 (12.9). RESULTS We found a 5-year CVD relative risk reduction of 6.1 % (95%CI 5.9,6.3) and 11.1 % (10.0,12.2) in the subgroup with albuminuria with similar results for the 10-year CVD risk. For the estimated 5-year risk of ESKD, we found a relative risk reduction of 5.3 % (5.1,5.4) with 7.6 % (6.9,8.4) in the subgroup with albuminuria. CONCLUSION We found a significant CVD and ESKD risk reduction, especially in the subgroup with albuminuria.
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Affiliation(s)
| | - Peter Rossing
- Complication Research, Steno Diabetes Center Copenhagen, Capital Region, Denmark; Department of Clinical Medicine, University of Copenhagen, Capital Region, Denmark
| | - David Cherney
- Department of Medicine, University of Toronto, Division of Nephrology, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Dorte Vistisen
- Clinical Epidemiology, Steno Diabetes Center Copenhagen, Capital Region, Denmark; Department of Public Health, University of Copenhagen, Capital Region, Denmark
| | - Frederik Persson
- Complication Research, Steno Diabetes Center Copenhagen, Capital Region, Denmark
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