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Neuen BL, Tuttle KR, Vaduganathan M. Accelerated Risk-Based Implementation of Guideline-Directed Medical Therapy for Type 2 Diabetes and Chronic Kidney Disease. Circulation 2024; 149:1238-1240. [PMID: 38620082 DOI: 10.1161/circulationaha.123.068524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N.)
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia (B.L.N.)
- Division of Cardiovascular Medicine, Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.L.N., M.V.)
| | - Katherine R Tuttle
- University of Washington and Providence Medical Research Center, Providence Health Care, Spokane (K.R.T.)
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.L.N., M.V.)
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Fletcher RA, Herrington WG, Agarwal R, Mayne KJ, Arnott C, Jardine MJ, Mahaffey KW, Perkovic V, Staplin N, Wheeler DC, Chertow GM, Heerspink HJL, Neuen BL. Effects of SGLT2 inhibitors on cause-specific cardiovascular death in patients with chronic kidney disease: a meta-analysis of CKD progression trials. Clin J Am Soc Nephrol 2024:01277230-990000000-00370. [PMID: 38622766 DOI: 10.2215/cjn.0000000000000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/11/2024] [Indexed: 04/17/2024]
Affiliation(s)
- Robert A Fletcher
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, Indianapolis, IN, USA
| | - Kaitlin J Mayne
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Clare Arnott
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Meg J Jardine
- NHMRC Clinical Trials Centre, University of Sydney, New South Wales, Australia
- Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, UNSW, Sydney, New South Wales, Australia
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - David C Wheeler
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Department of Renal Medicine, University College London, London, UK
| | - Glenn M Chertow
- Departments of Medicine, Epidemiology and Population Health, and Health Policy, Stanford University School of Medicine, Stanford, CA, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
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de Oliveira Costa J, Lin J, Milder TY, Greenfield JR, Day RO, Stocker SL, Neuen BL, Havard A, Pearson SA, Falster MO. Geographic variation in sodium-glucose cotransporter 2 inhibitor and glucagon-like peptide-1 receptor agonist use in people with type 2 diabetes in New South Wales, Australia. Diabetes Obes Metab 2024. [PMID: 38618983 DOI: 10.1111/dom.15597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
AIM Sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) improve glycaemic control and cardio-renal outcomes for people with type 2 diabetes (T2D). However, geographic and socio-economic variation in use is not well understood. METHODS We identified 367 829 New South Wales residents aged ≥40 years who dispensed metformin in 2020 as a proxy for T2D. We estimated the prevalence of use of other glucose-lowering medicines among people with T2D and the prevalence of SGLT2i and GLP-1RA use among people using concomitant T2D therapy (i.e. metformin + another glucose-lowering medicine). We measured the prevalence by small-level geography, stratified by age group, and characterized by remoteness and socio-economic status. RESULTS The prevalence of SGLT2i (29.7%) and GLP-1RA (8.3%) use in people with T2D aged 40-64 increased with geographic remoteness and in areas of greater socio-economic disadvantage, similar to other glucose-lowering medicines. The prevalence of SGLT2i (55.4%) and GLP-1RA (15.4%) among people using concomitant T2D therapy varied across geographic areas, with lower SGLT2i use in more disadvantaged areas and localized areas of high GLP-1RA use (2.5 times the median). Compared with people aged 40-64 years, the prevalence of SGLT2i and GLP-1RA use was lower in older age groups, but with similar patterns of variation across geographic areas. CONCLUSIONS The prevalence of SGLT2i and GLP-1RA use varied by geography, probably reflecting a combination of system- and prescriber-level factors. Socio-economic variation in GLP-1RA use was overshadowed by localized patterns of prescribing. Continued monitoring of variation can help shape interventions to optimize use among people who would benefit the most.
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Affiliation(s)
- Juliana de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jialing Lin
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Tamara Y Milder
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Alys Havard
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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Patel SM, Kang YM, Im K, Neuen BL, Anker SD, Bhatt DL, Butler J, Cherney DZI, Claggett BL, Fletcher RA, Herrington WG, Inzucchi SE, Jardine MJ, Mahaffey KW, McGuire DK, McMurray JJV, Neal B, Packer M, Perkovic V, Solomon SD, Staplin N, Vaduganathan M, Wanner C, Wheeler DC, Zannad F, Zhao Y, Heerspink HJL, Sabatine MS, Wiviott SD. Sodium Glucose Co-transporter 2 Inhibitors and Major Adverse Cardiovascular Outcomes: A SMART-C Collaborative Meta-Analysis. Circulation 2024. [PMID: 38583093 DOI: 10.1161/circulationaha.124.069568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/30/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Sodium glucose co-transporter 2 inhibitors (SGLT2i) consistently improve heart failure and kidney-related outcomes; however, effects on major adverse cardiovascular events (MACE) across different patient populations are less clear. METHODS This was a collaborative trial-level meta-analysis from the SGLT2i meta-analysis cardio-renal trialists consortium, which includes all phase 3, placebo-controlled, outcomes trials of SGLT2i across three patient populations (diabetes at high risk for atherosclerotic cardiovascular disease [ASCVD], heart failure [HF], or chronic kidney disease [CKD]). The outcomes of interest were MACE (composite of CV death, myocardial infarction [MI], or stroke), individual components of MACE (inclusive of fatal and non-fatal events), all-cause mortality, and death subtypes. Effect estimates for SGLT2i vs. placebo were meta-analyzed across trials and examined across key subgroups (established ASCVD, prior MI, diabetes, prior HF, albuminuria, CKD stages and risk groups). RESULTS A total of 78,607 patients across 11 trials were included: 42,568 (54.2%), 20,725 (26.4%), and 15,314 (19.5%) were included from trials of patients with diabetes at high risk for ASCVD, HF, or CKD, respectively. SGLT2i reduced the rate of MACE by 9% (HR 0.91 [95% CI 0.87-0.96], p<0.0001) with a consistent effect across all three patient populations (I2=0%) and across all key subgroups. This effect was primarily driven by a reduction in CV death (HR 0.86 [0.81-0.92], p<0.0001), with no significant effect for MI in the overall population (HR 0.95 [0.87-1.04], p=0.29), and no effect on stroke (HR 0.99 [0.91-1.07], p=0.77). The benefit for CV death was driven primarily by reductions in HF death and sudden cardiac death (HR 0.68 [0.46-1.02] and HR 0.86 [0.78-0.95], respectively) and was generally consistent across subgroups, with the possible exception of being more apparent in those with albuminuria (Pint=0.02). CONCLUSIONS SGLT2i reduce the risk of MACE across a broad range of patients irrespective of ASCVD, diabetes, kidney function or other major clinical characteristics at baseline. This effect is driven primarily by a reduction of CV death, particularly HF and sudden cardiac death, without a significant effect on MI in the overall population, and no effect on stroke. These data may help inform selection for SGLT2i therapies across the spectrum of cardiovascular-kidney-metabolic disease.
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Affiliation(s)
- Siddharth M Patel
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Yu Mi Kang
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - KyungAh Im
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Brendon L Neuen
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Stefan D Anker
- Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX; Department of Medicine, University of Mississippi School of Medicine, Jackson, MS
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, Ontario, Canada
| | - Brian L Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Robert A Fletcher
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - William G Herrington
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | - Meg J Jardine
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR), Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Parkland Health, Dallas, TX
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX and Imperial College, London United Kingdom
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Natalie Staplin
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Christoph Wanner
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center (CHFC), University Hospital, Würzburg, Germany
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Faiez Zannad
- Université de Lorraine, Inserm Centre d'Investigations Cliniques Plurithématique 1433, and CHRU, Nancy, France
| | | | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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5
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Chatur S, Neuen BL, Claggett BL, Beldhuis IE, Mc Causland FR, Desai AS, Rouleau JL, Zile MR, Lefkowitz MP, Packer M, McMurray JJ, Solomon SD, Vaduganathan M. Effects of Sacubitril/Valsartan Across the Spectrum of Renal Impairment in Patients With Heart Failure. J Am Coll Cardiol 2024:S0735-1097(24)06691-9. [PMID: 38588927 DOI: 10.1016/j.jacc.2024.03.392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The Kidney Disease Improving Global Outcomes (KDIGO) classification integrates both estimated glomerular filtration rate(eGFR) and urine-albumin-creatinine-ratio to stratify risk more comprehensively in patients with chronic kidney disease. There are limited data assessing whether this classification system is associated with prognosis and treatment response in heart failure populations. METHODS PARADIGM-HF was a global RCT evaluating sacubitril/valsartan vs. enalapril in patients with HFrEF. Patients were classified according to low, moderate, and high/very high KDIGO risk. Treatment responses were assessed according to baseline KDIGO risk. The primary outcome was a composite of CV death or HF hospitalization. A renal composite outcome was defined as sustained decline in eGFR by ≥40% or end stage kidney disease. RESULTS Among 1,910 (23% of total) participants with available data, 42%, 32%, and 26% were classified as low, moderate, and high/very high KDIGO risk, respectively. Patients in the highest KDIGO risk categories experienced the highest rates of the primary composite outcome (7.6[6.5-9.0], 9.4[7.9-11.2], 14.9[12.7-17.6] per 100py; P<0.001). Sacubitril/valsartan had a similar safety profile and similarly reduced the risk of both the primary outcome (PInteraction=0.31) and the renal composite outcome (PInteraction=0.50) across the spectrum of KDIGO risk. CONCLUSION One in 4 patients with HFrEF were classified as at least high KDIGO kidney risk; these individuals faced concordantly the highest risks of CV events. Sacubitril/valsartan exhibited consistent CV and kidney protective benefits as well as safety across the spectrum of baseline kidney risk. These data further support initiation of sacubitril/valsartan in HFrEF across a broad range of kidney risk.
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Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brendon L Neuen
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Iris E Beldhuis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; University of Groningen, Department of Cardiology, University of Medical Center Groningen, The Netherlands
| | - Finnian R Mc Causland
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Michael R Zile
- Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | | | - Milton Packer
- Baylor University Medical Center, Dallas, Texas, USA
| | - John Jv McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Francis A, Wainstein M, Irish G, Abdul Hafidz MI, Chen T, Cho Y, Htay H, Kanjanabuch T, Lalji R, Neuen BL, See E, Shah A, Smyth B, Tungsanga S, Viecelli A, Yeung EK, Arruebo S, Bello AK, Caskey FJ, Damster S, Donner JA, Jha V, Johnson DW, Levin A, Malik C, Nangaku M, Okpechi IG, Tonelli M, Ye F, Wong MG, Bavanandan S. Capacity for the management of kidney failure in the International Society of Nephrology Oceania and South East Asia (OSEA) region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA). Kidney Int Suppl (2011) 2024; 13:110-122. [PMID: 38618497 PMCID: PMC11010617 DOI: 10.1016/j.kisu.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 04/16/2024] Open
Abstract
The International Society of Nephrology (ISN) region of Oceania and South East Asia (OSEA) is a mix of high- and low-income countries, with diversity in population demographics and densities. Three iterations of the ISN-Global Kidney Health Atlas (GKHA) have been conducted, aiming to deliver in-depth assessments of global kidney care across the spectrum from early detection of CKD to treatment of kidney failure. This paper reports the findings of the latest ISN-GKHA in relation to kidney-care capacity in the OSEA region. Among the 30 countries and territories in OSEA, 19 (63%) participated in the ISN-GKHA, representing over 97% of the region's population. The overall prevalence of treated kidney failure in the OSEA region was 1203 per million population (pmp), 45% higher than the global median of 823 pmp. In contrast, kidney replacement therapy (KRT) in the OSEA region was less available than the global median (chronic hemodialysis, 89% OSEA region vs. 98% globally; peritoneal dialysis, 72% vs. 79%; kidney transplantation, 61% vs. 70%). Only 56% of countries could provide access to dialysis to at least half of people with incident kidney failure, lower than the global median of 74% of countries with available dialysis services. Inequalities in access to KRT were present across the OSEA region, with widespread availability and low out-of-pocket costs in high-income countries and limited availability, often coupled with large out-of-pocket costs, in middle- and low-income countries. Workforce limitations were observed across the OSEA region, especially in lower-middle-income countries. Extensive collaborative work within the OSEA region and globally will help close the noted gaps in kidney-care provision.
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Affiliation(s)
- Anna Francis
- Department of Nephrology, Queensland Children’s Hospital, South Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Marina Wainstein
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- West Moreton Kidney Health Service, Ipswich Hospital, Brisbane, Queensland, Australia
| | - Georgina Irish
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, South Australia Health, Adelaide, South Australia, Australia
| | | | - Titi Chen
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Faculty of Medicine and Health, the University of Sydney, Camperdown, New South Wales, Australia
- The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Yeoungjee Cho
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network at the University of Queensland, Brisbane, Queensland, Australia
| | - Htay Htay
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Rowena Lalji
- Department of Nephrology, Queensland Children’s Hospital, South Brisbane, Queensland, Australia
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Queensland, Australia
- Metro South and Integrated Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Brendon L. Neuen
- Kidney Trials Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Emily See
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Nephrology, Royal Children’s Hospital, Parkville, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Anim Shah
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | - Brendan Smyth
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Australia
- Department of Renal Medicine, St George Hospital, Kogarah, Australia
| | - Somkanya Tungsanga
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Division of General Internal Medicine-Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Andrea Viecelli
- Australasian Kidney Trials Network at the University of Queensland, Brisbane, Queensland, Australia
- Department of Kidney and Transplant Services, Division of Medicine, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- University of Queensland, Queensland, Australia
| | - Emily K. Yeung
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia
| | - Silvia Arruebo
- The International Society of Nephrology, Brussels, Belgium
| | - Aminu K. Bello
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Fergus J. Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Jo-Ann Donner
- The International Society of Nephrology, Brussels, Belgium
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India
- School of Public Health, Imperial College, London, UK
- Manipal Academy of Higher Education, Manipal, India
| | - David W. Johnson
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network at the University of Queensland, Brisbane, Queensland, Australia
- Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charu Malik
- The International Society of Nephrology, Brussels, Belgium
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ikechi G. Okpechi
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Canada and Pan-American Health Organization/World Health Organization’s Collaborating Centre in Prevention and Control of Chronic Kidney Disease, University of Calgary, Calgary, Alberta, Canada
| | - Feng Ye
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Muh Geot Wong
- Faculty of Medicine and Health, the University of Sydney, Camperdown, New South Wales, Australia
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Sunita Bavanandan
- Department of Nephrology Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
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Tobe SW, Mavrakanas TA, Bajaj HS, Levin A, Tangri N, Slee A, Neuen BL, Perkovic V, Mahaffey KW, Rapattoni W, Ang FG. Impact of Canagliflozin on Kidney and Cardiovascular Outcomes by Type 2 Diabetes Duration: A Pooled Analysis of the CANVAS Program and CREDENCE Trials. Diabetes Care 2024; 47:501-507. [PMID: 38252809 PMCID: PMC10909678 DOI: 10.2337/dc23-1450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVE The study was undertaken because it was unknown whether the duration of type 2 diabetes modifies the effects of sodium-glucose cotransporter 2 inhibitor canagliflozin on cardiovascular (CV) and kidney outcomes. RESEARCH DESIGN AND METHODS This post hoc analysis of the Canagliflozin Cardiovascular Assessment Study (CANVAS) Program (N = 10,142) and Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants With Diabetic Nephropathy (CREDENCE) trial (N = 4,401) evaluated hazard ratios and 95% CIs using Cox proportional hazards for the effects of canagliflozin on CV and kidney outcomes, including progression and regression of albuminuria over 5-year intervals of disease duration. RESULTS Canagliflozin had ranges of benefit across intervals of diabetes duration, with no heterogeneity for major adverse CV events, CV death or heart failure hospitalization, and kidney failure requiring therapy or doubling serum creatinine. Furthermore, canagliflozin reduced albuminuria progression and increased albuminuria regression with no interaction across all diabetes duration subgroups. CONCLUSIONS Our findings suggest that earlier treatment with canagliflozin confers consistent cardiorenal benefits to individuals with type 2 diabetes.
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Affiliation(s)
- Sheldon W. Tobe
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Thomas A. Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Quebec, Canada
| | | | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Brendon L. Neuen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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Ha JT, Freedman SB, Kelly DM, Neuen BL, Perkovic V, Jun M, Badve SV. Kidney Function, Albuminuria, and Risk of Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis. Am J Kidney Dis 2024; 83:350-359.e1. [PMID: 37777059 DOI: 10.1053/j.ajkd.2023.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 10/02/2023]
Abstract
RATIONALE & OBJECTIVE Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist. However, it is not known whether CKD is an independent risk factor for incident AF. Therefore, we evaluated the association between markers of CKD-estimated glomerular filtration rate (eGFR) and albuminuria-and incident AF. STUDY DESIGN Systematic review and meta-analysis of cohort studies and randomized controlled trials. SETTING & STUDY POPULATIONS Participants with measurement of eGFR and/or albuminuria who were not receiving dialysis. SELECTION CRITERIA FOR STUDIES Cohort studies and randomized controlled trials were included that reported incident AF risk in adults according to eGFR and/or albuminuria. ANALYTICAL APPROACH Age- or multivariate-adjusted risk ratios (RRs) for incident AF were extracted from cohort studies, and RRs for each trial were derived from event data. RRs for incident AF were pooled using random-effects models. RESULTS 38 studies involving 28,470,249 participants with 530,041 incident AF cases were included. Adjusted risk of incident AF was greater among participants with lower eGFR than those with higher eGFR (eGFR<60 vs≥60mL/min/1.73m2: RR, 1.43; 95% CI, 1.30-1.57; and eGFR<90 vs≥90mL/min/1.73m2: RR, 1.42; 95% CI, 1.26-1.60). Adjusted incident AF risk was greater among participants with albuminuria (any albuminuria vs no albuminuria: RR, 1.43; 95% CI, 1.25-1.63; and moderately to severely increased albuminuria vs normal to mildly increased albuminuria: RR, 1.64; 95% CI, 1.31-2.06). Subgroup analyses showed an exposure-dependent association between CKD and incident AF, with the risk increasing progressively at lower eGFR and higher albuminuria categories. LIMITATIONS Lack of patient-level data, interaction between eGFR and albuminuria could not be evaluated, possible ascertainment bias due to variation in the methods of AF detection. CONCLUSIONS Lower eGFR and greater albuminuria were independently associated with increased risk of incident AF. CKD should be regarded as an independent risk factor for incident AF. PLAIN-LANGUAGE SUMMARY Irregular heartbeat, or atrial fibrillation (AF), is the commonest abnormal heart rhythm. AF occurs commonly in people with chronic kidney disease (CKD), and CKD is also common in people with AF. However, CKD in not widely recognized as a risk factor for new-onset or incident AF. In this research, we combined data on more than 28 million participants in 38 studies to determine whether CKD itself increases the chances of incident AF. We found that both commonly used markers of kidney disease (estimated glomerular filtration rate and albuminuria, ie, protein in the urine) were independently associated with a greater risk of incident AF. This finding suggests that CKD should be recognized as an independent risk factor for incident AF.
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Affiliation(s)
- Jeffrey T Ha
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia
| | - S Ben Freedman
- Heart Research Institute, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Dearbhla M Kelly
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Global Brain Health Institute, Trinity College Dublin, Ireland
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Min Jun
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Sunil V Badve
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia.
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Sharma A, Razaghizad A, Joury A, Levin A, Bajaj HS, Mancini GBJ, Wong NC, Slee A, Ang FG, Rapattoni W, Neuen BL, Arnott C, Perkovic V, Mahaffey KW. Primary and Secondary Cardiovascular and Kidney Prevention With Canagliflozin: Insights From the CANVAS Program and CREDENCE Trial. J Am Heart Assoc 2024; 13:e031586. [PMID: 38240199 PMCID: PMC11056176 DOI: 10.1161/jaha.123.031586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/28/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND This study evaluated the effects of canagliflozin in patients with type 2 diabetes with and without prevalent cardiovascular disease (secondary and primary prevention). METHODS AND RESULTS This was a pooled participant-level analysis of the CANVAS (Canagliflozin Cardiovascular Assessment Study) Program and CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) trial. The CANVAS Program included participants with type 2 diabetes at elevated cardiovascular risk, whereas the CREDENCE trial included participants with type 2 diabetes and albuminuric chronic kidney disease. Hazard ratios (HRs) with interaction terms were obtained from Cox regression models to estimate relative risk reduction with canagliflozin versus placebo across the primary and secondary prevention groups. We analyzed 5616 (38.9%) and 8804 (61.1%) individuals in the primary and secondary prevention subgroups, respectively. Primary versus secondary prevention participants were on average younger (62.2 versus 63.8 years of age) and more often women (42% versus 31%). Canagliflozin reduced the risk of major adverse cardiovascular events (HR, 0.84 [95% CI, 0.76-0.94]) consistently across primary and secondary prevention subgroups (Pinteraction=0.86). Similarly, no treatment effect heterogeneity was observed with canagliflozin for hospitalization for heart failure, cardiovascular death, end-stage kidney disease, or all-cause mortality (all Pinteraction>0.5). CONCLUSIONS Canagliflozin reduced cardiovascular and kidney outcomes with no statistical evidence of heterogeneity for the treatment effect across the primary and secondary prevention subgroups in the CANVAS Program and CREDENCE trial. Although studies on the optimal implementation of canagliflozin within these populations are warranted, these results reinforce canagliflozin's role in cardiorenal prevention and treatment in individuals with type 2 diabetes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01032629, NCT01989754, NCT02065791.
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Affiliation(s)
- Abhinav Sharma
- Centre for Outcomes Research and Evaluation Research Institute of the McGill University Health CentreMontrealQCCanada
- Division of CardiologyMcGill University Health Centre, McGill UniversityMontrealQCCanada
- DREAM‐CV LaboratoryMcGill University Health Centre, McGill UniversityMontrealQCCanada
| | - Amir Razaghizad
- Centre for Outcomes Research and Evaluation Research Institute of the McGill University Health CentreMontrealQCCanada
- Division of CardiologyMcGill University Health Centre, McGill UniversityMontrealQCCanada
- DREAM‐CV LaboratoryMcGill University Health Centre, McGill UniversityMontrealQCCanada
| | - Abdulaziz Joury
- Centre for Outcomes Research and Evaluation Research Institute of the McGill University Health CentreMontrealQCCanada
- Division of CardiologyMcGill University Health Centre, McGill UniversityMontrealQCCanada
- DREAM‐CV LaboratoryMcGill University Health Centre, McGill UniversityMontrealQCCanada
- King Salman Heart Center, King Fahad Medical CityRiyadhSaudi Arabia
| | - Adeera Levin
- Division of NephrologyUniversity of British ColumbiaVancouverBCCanada
| | | | - G. B. John Mancini
- Centre for Cardiovascular InnovationUniversity of British ColumbiaVancouverBCCanada
| | | | | | | | | | - Brendon L. Neuen
- The George Institute for Global Health, UNSW SydneySydneyAustralia
- Royal North Shore HospitalSydneyAustralia
| | - Clare Arnott
- The George Institute for Global Health, UNSW SydneySydneyAustralia
- Faculty of Medicine, UNSW SydneySydneyAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyAustralia
- Sydney Medical SchoolUniversity of SydneyAustralia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW SydneySydneyAustralia
- Royal North Shore HospitalSydneyAustralia
- Faculty of Medicine, UNSW SydneySydneyAustralia
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Department of MedicineStanford University School of MedicineStanfordCA
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10
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Neuen BL, Heerspink HJL, Vart P, Claggett BL, Fletcher RA, Arnott C, de Oliveira Costa J, Falster MO, Pearson SA, Mahaffey KW, Neal B, Agarwal R, Bakris G, Perkovic V, Solomon SD, Vaduganathan M. Estimated Lifetime Cardiovascular, Kidney, and Mortality Benefits of Combination Treatment With SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Nonsteroidal MRA Compared With Conventional Care in Patients With Type 2 Diabetes and Albuminuria. Circulation 2024; 149:450-462. [PMID: 37952217 DOI: 10.1161/circulationaha.123.067584] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Sodium glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1 RA), and the nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone all individually reduce cardiovascular, kidney, and mortality outcomes in patients with type 2 diabetes and albuminuria. However, the lifetime benefits of combination therapy with these medicines are not known. METHODS We used data from 2 SGLT2i trials (CANVAS [Canagliflozin Cardiovascular Assessment] and CREDENCE [Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation]), 2 ns-MRA trials (FIDELIO-DKD [Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease] and FIGARO-DKD [Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and the Clinical Diagnosis of Diabetic Kidney Disease]), and 8 GLP-1 RA trials to estimate the relative effects of combination therapy versus conventional care (renin-angiotensin system blockade and traditional risk factor control) on cardiovascular, kidney, and mortality outcomes. Using actuarial methods, we then estimated absolute risk reductions with combination SGLT2i, GLP-1 RA, and ns-MRA in patients with type 2 diabetes and at least moderately increased albuminuria (urinary albumin:creatinine ratio ≥30 mg/g) by applying estimated combination treatment effects to participants receiving conventional care in CANVAS and CREDENCE. RESULTS Compared with conventional care, the combination of SGLT2i, GLP-1 RA, and ns-MRA was associated with a hazard ratio of 0.65 (95% CI, 0.55-0.76) for major adverse cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death). The corresponding estimated absolute risk reduction over 3 years was 4.4% (95% CI, 3.0-5.7), with a number needed to treat of 23 (95% CI, 18-33). For a 50-year-old patient commencing combination therapy, estimated major adverse cardiovascular event-free survival was 21.1 years compared with 17.9 years for conventional care (3.2 years gained [95% CI, 2.1-4.3]). There were also projected gains in survival free from hospitalized heart failure (3.2 years [95% CI, 2.4-4.0]), chronic kidney disease progression (5.5 years [95% CI, 4.0-6.7]), cardiovascular death (2.2 years [95% CI, 1.2-3.0]), and all-cause death (2.4 years [95% CI, 1.4-3.4]). Attenuated but clinically relevant gains in event-free survival were observed in analyses assuming 50% additive effects of combination therapy, including for major adverse cardiovascular events (2.4 years [95% CI, 1.1-3.5]), chronic kidney disease progression (4.5 years [95% CI, 2.8-5.9]), and all-cause death (1.8 years [95% CI, 0.7-2.8]). CONCLUSIONS In patients with type 2 diabetes and at least moderately increased albuminuria, combination treatment of SGLT2i, GLP-1 RA, and ns-MRA has the potential to afford relevant gains in cardiovascular and kidney event-free and overall survival.
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Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia (B.L.N.)
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
| | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, The Netherlands (H.J.L.H., P.V.)
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, The Netherlands (H.J.L.H., P.V.)
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
| | - Robert A Fletcher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.A.)
| | - Julianna de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia (J.d.O.C., M.O.F., S.-A.P.)
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia (J.d.O.C., M.O.F., S.-A.P.)
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Australia (J.d.O.C., M.O.F., S.-A.P.)
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
- Department of Epidemiology and Biostatistics, Imperial College London, United Kingdom (B.N.)
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, Indianapolis (R.A.)
| | - George Bakris
- Department of Medicine, University of Chicago, IL (G.B.)
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., H.J.L.H., R.A.F., C.A., B.N., V.P.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.N., B.L.C., S.D.S., M.V.)
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Sharma A, Marques P, Neuen BL, Fletcher RA, Slee A, Rapattoni W, Ang FG, Arnott C, Levin A, Verma S, Perkovic V, Mahaffey KW. Timing of statistical benefit of canagliflozin in patients with type 2 diabetes for cardiovascular and heart failure outcomes: Insights from the CANVAS Program and CREDENCE trial. Diabetes Obes Metab 2024; 26:758-762. [PMID: 37881140 DOI: 10.1111/dom.15340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/24/2023] [Accepted: 10/06/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Abhinav Sharma
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Pedro Marques
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - Robert A Fletcher
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - April Slee
- New Arch Consulting, Seattle, Washington, USA
| | | | | | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Faculty of Medicine, UNSW Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Adeera Levin
- St. Paul's Hospital, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Faculty of Medicine, UNSW Sydney, Sydney, Australia
- The Royal North Shore Hospital, Sydney, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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12
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Neuen BL, Jun M, Wick J, Kotwal S, Badve SV, Jardine MJ, Gallagher M, Chalmers J, Nallaiah K, Perkovic V, Peiris D, Rodgers A, Woodward M, Ronksley PE. Estimating the population-level impacts of improved uptake of SGLT2 inhibitors in patients with chronic kidney disease: a cross-sectional observational study using routinely collected Australian primary care data. Lancet Reg Health West Pac 2024; 43:100988. [PMID: 38192747 PMCID: PMC10772282 DOI: 10.1016/j.lanwpc.2023.100988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/27/2023] [Accepted: 11/28/2023] [Indexed: 01/10/2024]
Abstract
Background Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk of kidney failure and death in patients with chronic kidney disease (CKD) but are underused. We evaluated the number of patients with CKD in Australia that would be eligible for treatment and estimated the number of cardiorenal and kidney failure events that could be averted with improved uptake of SGLT2 inhibitors. Methods This cross-sectional observational study leveraged nationally representative primary care data from 392 Australian general practices (MedicineInsight) between 1 January 2020 and 31 December 2021. We identified patients that would have met inclusion criteria of key SGLT2 inhibitor trials and applied these data to age and sex-stratified estimates of CKD prevalence for the Australian population (using national census data), estimating the number of preventable events using trial event rates. Key outcomes included cardiorenal events (CKD progression, kidney failure, or death due to cardiovascular or kidney disease) and kidney failure. Findings In MedicineInsight, 44.2% of adults with CKD would have met CKD eligibility criteria for an SGLT2 inhibitor; baseline use was 4.1%. Applying these data to the Australian population, 230,246 patients with CKD would have been eligible for treatment with an SGLT2 inhibitor. Optimal implementation of SGLT2 inhibitors (75% uptake) could reduce cardiorenal and kidney failure events annually in Australia by 3644 (95% CI 3526-3764) and 1312 (95% CI 1242-1385), respectively. Interpretation Improved uptake of SGLT2 inhibitors for patients with CKD in Australia has the potential to prevent large numbers of patients experiencing CKD progression or dying due to cardiovascular or kidney disease. Identifying strategies to increase the uptake of SGLT2 inhibitors is critical to realising the population-level benefits of this drug class. Funding University of New South Wales Scientia Program and Boehringer IngelheimEli Lilly Alliance.
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Affiliation(s)
- Brendon L. Neuen
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Min Jun
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - James Wick
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sradha Kotwal
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Nephrology, Prince of Wales Hospital, Sydney, Australia
| | - Sunil V. Badve
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
| | - Meg J. Jardine
- NHMRC Clinical Trials Centre, University of Sydney, New South Wales, Australia
- Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Martin Gallagher
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Renal Medicine, Liverpool Hospital, Sydney, Australia
| | - John Chalmers
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Kellie Nallaiah
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Vlado Perkovic
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - David Peiris
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anthony Rodgers
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Mark Woodward
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Paul E. Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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13
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Jain SS, Yu J, Arnott C, Neal B, Perkovic V, Neuen BL, Jardine M, Mahaffey KW. Treatment effect of canagliflozin for patients on therapy for heart failure: Pooled analysis of the CANVAS program and CREDENCE trial. Int J Cardiol 2024; 395:131444. [PMID: 37844669 DOI: 10.1016/j.ijcard.2023.131444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 09/12/2023] [Accepted: 10/12/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Canagliflozin is a sodium-glucose cotransporter 2 inhibitor that has been shown to reduce cardiovascular events in diabetic patients with and without heart failure (HF). Whether the clinical benefits and safety profile of canagliflozin are different in those on a beta blocker and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (BB + RAASi) is unknown. METHODS We pooled participants with HF at baseline from the CANVAS Program and CREDENCE trial and assessed major adverse cardiovascular events and its components; hospitalization for heart failure (HHF); HHF or CV death; all-cause mortality; a renal composite; and a combined renal and CV composite. RESULTS Of 14,543 participants, 2113 had HF at baseline, and 1280 were on BB + RAASi. In those with a history of HF, participants on BB + RAASi therapy were more likely to have coronary atherosclerotic disease (82 vs 72%, p < 0.001), history of myocardial infarction (42 vs 29%, p < 0.001), higher mean body mass index (34 vs 32 kg/m2, p < 0.001), and lower mean estimated glomerular filtration rate (67 vs 70 mL/min/1.73 m2, p < 0.01). They were also more likely to be on insulin, a statin, antithrombotic agent, and a diuretic (all p < 0.001). In unadjusted analysis and when adjusted for selected baseline factors, there was no heterogeneity in canagliflozin treatment effect except for HHF/CV death in those on baseline BB + RAASi vs. those not on baseline BB + RAASi (Pheterogeneity = 0.02). CONCLUSION Canagliflozin mostly improved CV and kidney outcomes in participants with a history of HF irrespective of use of BB + RAASi at baseline, with possible greater benefit on HHF/CV death in participants on BB + RAASi.
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Affiliation(s)
- Sneha S Jain
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, United States of America
| | - Jie Yu
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Sydney, Australia; Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Clare Arnott
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; The Charles Perkins Centre, University of Sydney, Sydney, Australia; Faculty of Clinical Epidemiology, Imperial College London, London, UK
| | - Vlado Perkovic
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Sydney, Australia
| | - Brendon L Neuen
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Sydney, Australia
| | - Meg Jardine
- The George Institute for Global health, UNSW Sydney, Sydney, Australia; Concord Repatriation General Hospital, Sydney, New South Wales, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Kenneth W Mahaffey
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, United States of America; Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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14
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Fletcher RA, Jongs N, Chertow GM, McMurray JJ, Arnott C, Jardine MJ, Mahaffey KW, Perkovic V, Rockenschaub P, Rossing P, Correa-Rotter R, Toto RD, Vaduganathan M, Wheeler DC, Heerspink HJ, Neuen BL. Effect of SGLT2 Inhibitors on Discontinuation of Renin-angiotensin System Blockade: A Joint Analysis of the CREDENCE and DAPA-CKD Trials. J Am Soc Nephrol 2023; 34:1965-1975. [PMID: 37876229 PMCID: PMC10703073 DOI: 10.1681/asn.0000000000000248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/25/2023] [Indexed: 10/26/2023] Open
Abstract
SIGNIFICANCE STATEMENT Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are foundational therapy for CKD but are underused, in part because they are frequently withheld and not restarted due to hyperkalemia, AKI, or hospitalization. Consequently, ensuring persistent use of ACE inhibitors and ARBs in CKD has long been a major clinical priority. In this joint analysis of the CREDENCE and DAPA-CKD trials, the relative risk of discontinuation of ACE inhibitors and ARBs was reduced by 15% in patients randomized to sodium-glucose cotransporter 2 (SGLT2) inhibitors. This effect was more pronounced in patients with urine albumin:creatinine ratio ≥1000 mg/g, for whom the absolute benefits of these medications are the greatest. These findings indicate that SGLT2 inhibitors may enable better use of ACE inhibitors and ARBs in patients with CKD. BACKGROUND Strategies to enable persistent use of renin-angiotensin system (RAS) blockade to improve outcomes in CKD have long been sought. The effect of SGLT2 inhibitors on discontinuation of RAS blockade has yet to be evaluated. METHODS We conducted a joint analysis of canagliflozin and renal events in diabetes with established nephropathy clinical evaluation (CREDENCE) and dapagliflozin and prevention of adverse outcomes in CKD (DAPA-CKD), two randomized, double-blind, placebo-controlled, event-driven trials of SGLT2 inhibitors in patients with albuminuric CKD. The main outcome was time to incident temporary or permanent discontinuation of RAS blockade, defined as interruption of an ACE inhibitor or ARB for at least 4 weeks or complete cessation during the double-blind on-treatment period. Cox regression analyses were used to estimate the treatment effects from each trial. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were pooled with fixed effects meta-analysis to obtain summary treatment effects, overall and across key subgroups. RESULTS During median follow-up of 2.2 years across both trials, 740 of 8483 (8.7%) patients discontinued RAS blockade. The relative risk for discontinuation of RAS blockade was 15% lower in patients randomized to receiving SGLT2 inhibitors (HR, 0.85; 95% CI, 0.74 to 0.99), with consistent effects across trials ( P -heterogeneity = 0.92). The relative effect on RAS blockade discontinuation was more pronounced among patients with baseline urinary albumin:creatinine ratio ≥1000 mg/g (pooled HR, 0.77; 95% CI, 0.63 to 0.94; P -heterogeneity = 0.009). CONCLUSIONS In patients with albuminuric CKD with and without type 2 diabetes, SGLT2 inhibitors facilitate the use of RAS blockade. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ClinicalTrials.gov, NCT02065791 and NCT03036150 . PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_11_21_JASN0000000000000248.mp3.
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Affiliation(s)
- Robert A. Fletcher
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Glenn M. Chertow
- Departments of Medicine, Epidemiology and Population Health, and Health Policy, Stanford University School of Medicine, Stanford, California
| | - John J.V. McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Clare Arnott
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Meg J. Jardine
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- NHMRC Clinical Trials Centre, University of Sydney, New South Wales, Australia
| | - Kenneth W. Mahaffey
- Department of Medicine, Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, California
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, UNSW, Sydney, New South Wales, Australia
| | - Patrick Rockenschaub
- Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
- QUEST Center for Transforming Biomedical Research, Berlin Institute of Health (BIH), Berlin, Germany
| | - Peter Rossing
- Complications Research, Steno Diabetes Center Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ricardo Correa-Rotter
- National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | - Robert D. Toto
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | | | - David C. Wheeler
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Hiddo J.L. Heerspink
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Brendon L. Neuen
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
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Yu J, Sweeting AN, Gianacas C, Houston L, Lee V, Fletcher RA, Perkovic V, Li Q, Neuen BL, Berwanger O, Heerspink HJL, de Zeeuw D, Arnott C. The effects of canagliflozin in type 2 diabetes in subgroups defined by population-specific body mass index: Insights from the CANVAS Program and CREDENCE trial. Diabetes Obes Metab 2023; 25:3724-3735. [PMID: 37671609 DOI: 10.1111/dom.15267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/07/2023]
Abstract
AIM To assess the effects of canagliflozin on clinical outcomes and intermediate markers across population-specific body mass index (BMI) categories in the CANVAS Program and CREDENCE trial. METHODS Individual participant data were pooled and analysed in subgroups according to population-specific BMI. The main outcomes of interest were: major adverse cardiovascular events (MACE, a composite of nonfatal myocardial infarction, nonfatal stroke or cardiovascular death); composite renal outcome; and changes in systolic blood pressure (SBP), body weight, albuminuria and estimated glomerular filtration rate (eGFR) slope. Cox proportional hazards models and mixed-effect models were used. RESULTS A total of 14 520 participants were included, of whom 9378 (65%) had obesity. Overall, canagliflozin reduced the risk of MACE (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.75 to 0.93) with no heterogeneity of treatment effect across BMI subgroups (Pheterogeneity = 0.76). Similarly, canagliflozin reduced composite renal outcomes (HR 0.75, 95% CI 0.66 to 0.84) with no heterogeneity across subgroups observed (Pheterogeneity = 0.72). The effects of canagliflozin on body weight and SBP differed across BMI subgroups (Pheterogeneity <0.01 and 0.04, respectively) but were consistent for albuminuria (Pheterogeneity = 0.60). Chronic eGFR slope with canagliflozin treatment was consistent across subgroups (Pheterogeneity >0.95). CONCLUSIONS The cardiovascular and renal benefits of canagliflozin and its safety profile were consistent across population-specific BMI subgroups for adults in the CANVAS Program and CREDENCE trial.
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Affiliation(s)
- Jie Yu
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Arianne N Sweeting
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The Charles Perkins Centre, University of Sydney, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Chris Gianacas
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Lauren Houston
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Vivian Lee
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Robert A Fletcher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Otavio Berwanger
- The George Institute for Global Health UK Office, Imperial College London, London, UK
| | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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16
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Beal B, Schutte AE, Neuen BL. Blood Pressure Effects of SGLT2 Inhibitors: Mechanisms and Clinical Evidence in Different Populations. Curr Hypertens Rep 2023; 25:429-435. [PMID: 37948021 DOI: 10.1007/s11906-023-01281-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Sodium glucose transporter 2 inhibitors (SGLT2 inhibitors) are increasingly prescribed due to their considerable benefits on clinical outcomes in people with diabetes, heart failure, and chronic kidney disease (CKD). Hypertension is a common comorbidity in each of these disease states, increasing risk of cardiovascular morbidity and mortality. We herein review the effects of SGLT2 inhibitors on blood pressure in different populations, proposed mechanisms of action, and the contribution of blood pressure lowering to end-organ protection. RECENT FINDINGS A recognised effect of SGLT2 inhibitors in recent clinical trials is blood pressure lowering, with multiple postulated mechanisms. This advantageous effect was first identified in populations with type 2 diabetes mellitus, prior to expansion of these trials to broader cohorts. On our review, we identified that the blood pressure lowering effect of SGLT2 inhibitors appears to be a dose-independent class-effect, with a magnitude of effect comparable to that seen with a low dose hydrochlorothiazide. There is considerable evidence demonstrating that this effect is observed across populations including those with type 2 diabetes mellitus, chronic kidney disease, and resistant hypertension.
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Affiliation(s)
- Bryony Beal
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Aletta E Schutte
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Level 5, 1 King St Newtown 2042, Sydney, Australia
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Brendon L Neuen
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia.
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Level 5, 1 King St Newtown 2042, Sydney, Australia.
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Koshino A, Neuen BL, Jongs N, Pollock C, Greasley PJ, Andersson EM, Hammarstedt A, Karlsson C, Langkilde AM, Wada T, Heerspink HJL. Effects of dapagliflozin and dapagliflozin-saxagliptin on erythropoiesis, iron and inflammation markers in patients with type 2 diabetes and chronic kidney disease: data from the DELIGHT trial. Cardiovasc Diabetol 2023; 22:330. [PMID: 38017482 PMCID: PMC10685512 DOI: 10.1186/s12933-023-02027-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/12/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND This post-hoc analysis of the DELIGHT trial assessed effects of the SGLT2 inhibitor dapagliflozin on iron metabolism and markers of inflammation. METHODS Patients with type 2 diabetes and albuminuria were randomized to dapagliflozin, dapagliflozin and saxagliptin, or placebo. We measured hemoglobin, iron markers (serum iron, transferrin saturation, and ferritin), plasma erythropoietin, and inflammatory markers (urinary MCP-1 and urinary/serum IL-6) at baseline and week 24. RESULTS 360/461 (78.1%) participants had available biosamples. Dapagliflozin and dapagliflozin-saxagliptin, compared to placebo, increased hemoglobin by 5.7 g/L (95%CI 4.0, 7.3; p < 0.001) and 4.4 g/L (2.7, 6.0; p < 0.001) and reduced ferritin by 18.6% (8.7, 27.5; p < 0.001) and 18.4% (8.7, 27.1; p < 0.001), respectively. Dapagliflozin reduced urinary MCP-1/Cr by 29.0% (14.6, 41.0; p < 0.001) and urinary IL-6/Cr by 26.6% (9.1, 40.7; p = 0.005) with no changes in other markers. CONCLUSIONS Dapagliflozin increased hemoglobin and reduced ferritin and urinary markers of inflammation, suggesting potentially important effects on iron metabolism and inflammation. TRIAL REGISTRATION ClinicalTrials.gov NCT02547935.
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Affiliation(s)
- Akihiko Koshino
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, Australia
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Peter J Greasley
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Eva-Marie Andersson
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Ann Hammarstedt
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Cecilia Karlsson
- BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | | | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands.
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia.
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18
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Heerspink HJL, Vart P, Jongs N, Neuen BL, Bakris G, Claggett B, Vaduganathan M, McCausland F, Docherty KF, Jhund PS, Solomon SD, Perkovic V, McMurray JJV. Estimated lifetime benefit of novel pharmacological therapies in patients with type 2 diabetes and chronic kidney disease: A joint analysis of randomized controlled clinical trials. Diabetes Obes Metab 2023; 25:3327-3336. [PMID: 37580309 DOI: 10.1111/dom.15232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/07/2023] [Accepted: 07/19/2023] [Indexed: 08/16/2023]
Abstract
AIM To estimate the lifetime benefit of a combination treatment of sodium-glucose co-transporter 2 (SGLT2) inhibitors and mineralocorticoid-receptor antagonists (MRA) in patients with type 2 diabetes and chronic kidney disease (CKD). MATERIALS AND METHODS The cumulative effect of combination treatment was derived from trial-level estimates of the effect of an SGLT2 inhibitor (canagliflozin) and MRA (finerenone) from the CREDENCE (N = 4401) and FIDELIO (N = 5734) trials, respectively. The cumulative effect was applied to the control group of patients with type 2 diabetes in the DAPA-CKD trial (N = 1451) to estimate long-term gains in event-free and overall survival. The analysis was repeated in an observational study. The primary outcome was a composite endpoint of doubling of serum creatinine, end-stage kidney disease or death because of kidney failure. RESULTS The hazard ratio of combination treatment for the primary outcome was 0.50 [95% confidence interval (CI): 0.44, 0.57]. At age 50 years, the estimated event-free survival from the primary outcome was 16.7 years (95% CI: 18.1, 21.0) with combination treatment versus 10.0 years (95% CI: 6.8, 12.3) with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers resulting in an incremental gain of 6.7 years (95% CI: 5.5, 7.9). In an observational study, the estimated gain in event-free survival regarding primary outcome was 6.3 years (95% CI: 5.2, 7.3). In a conservative scenario, assuming low adherence (70% of the observed adherence) and less pronounced efficacy (70% of the observed efficacy with 2% yearly decline) of combination therapy, gain in event-free survival regarding primary outcome was 2.5 years (95% CI: 2.0, 2.9). CONCLUSIONS Combined disease-modifying treatment with an SGLT2 inhibitor and MRA in patients with type 2 diabetes and CKD may substantially increase the number of years free from kidney failure and mortality.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- The George Institute for Global Health, Sydney, Australia
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - George Bakris
- American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Finnian McCausland
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vlado Perkovic
- The George Institute for Global Health, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - John J V McMurray
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Heerspink HJL, Jongs N, Neuen BL. The authors reply. Kidney Int 2023; 104:617-618. [PMID: 37599020 DOI: 10.1016/j.kint.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/06/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands; The George Institute for Global Health, Sydney, New South Wales, Australia.
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, New South Wales, Australia
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Thomas MC, Neuen BL, Twigg SM, Cooper ME, Badve SV. SGLT2 inhibitors for patients with type 2 diabetes and CKD: a narrative review. Endocr Connect 2023; 12:e230005. [PMID: 37159343 PMCID: PMC10448577 DOI: 10.1530/ec-23-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/05/2023] [Indexed: 05/11/2023]
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors have recently emerged as an effective means to protect kidney function in people with type 2 diabetes and chronic kidney disease (CKD). In this review, we explore the role of SGLT2 inhibition in these individuals. SGLT2 inhibitors specifically act to inhibit sodium and glucose reabsorption in the early proximal tubule of the renal nephron. Although originally developed as glucose-lowering agents through their ability to induce glycosuria, it became apparent in cardiovascular outcome trials that the trajectory of kidney function decline was significantly slowed and the incidence of serious falls in kidney function was reduced in participants receiving an SGLT2 inhibitor. These observations have recently led to specific outcome trials in participants with CKD, including DAPA-CKD, CREDENCE and EMPA-KIDNEY, and real-world studies, like CVD-REAL-3, that have confirmed the observation of kidney benefits in this setting. In response, recent KDIGO Guidelines have recommended the use of SGLT2 inhibitors as first-line therapy in patients with CKD, alongside statins, renin-angiotensin-aldosterone system inhibitors and multifactorial risk factor management as indicated. However, SGLT2 inhibitors remain significantly underutilized in the setting of CKD. Indeed, an inertia paradox exists, with patients with more severe disease less likely to receive an SGLT2 inhibitor. Concerns regarding safety appear unfounded, as acute kidney injury, hyperkalaemia, major acute cardiovascular events and cardiac death in patients with CKD appear to be lower following SGLT2 inhibition. The first-in-class indication of dapagliflozin for CKD may begin a new approach to managing kidney disease in type 2 diabetes.
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Affiliation(s)
- Merlin C Thomas
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Stephen M Twigg
- The University of Sydney School of Medicine, Sydney, NSW, Australia
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Sunil V Badve
- The George Institute for Global Health, Sydney, NSW, Australia
- Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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Inker LA, Collier W, Greene T, Miao S, Chaudhari J, Appel GB, Badve SV, Caravaca-Fontán F, Del Vecchio L, Floege J, Goicoechea M, Haaland B, Herrington WG, Imai E, Jafar TH, Lewis JB, Li PKT, Maes BD, Neuen BL, Perrone RD, Remuzzi G, Schena FP, Wanner C, Wetzels JFM, Woodward M, Heerspink HJL. A meta-analysis of GFR slope as a surrogate endpoint for kidney failure. Nat Med 2023; 29:1867-1876. [PMID: 37330614 DOI: 10.1038/s41591-023-02418-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/24/2023] [Indexed: 06/19/2023]
Abstract
Glomerular filtration rate (GFR) decline is causally associated with kidney failure and is a candidate surrogate endpoint for clinical trials of chronic kidney disease (CKD) progression. Analyses across a diverse spectrum of interventions and populations is required for acceptance of GFR decline as an endpoint. In an analysis of individual participant data, for each of 66 studies (total of 186,312 participants), we estimated treatment effects on the total GFR slope, computed from baseline to 3 years, and chronic slope, starting at 3 months after randomization, and on the clinical endpoint (doubling of serum creatinine, GFR < 15 ml min-1 per 1.73 m2 or kidney failure with replacement therapy). We used a Bayesian mixed-effects meta-regression model to relate treatment effects on GFR slope with those on the clinical endpoint across all studies and by disease groups (diabetes, glomerular diseases, CKD or cardiovascular diseases). Treatment effects on the clinical endpoint were strongly associated with treatment effects on total slope (median coefficient of determination (R2) = 0.97 (95% Bayesian credible interval (BCI) 0.82-1.00)) and moderately associated with those on chronic slope (R2 = 0.55 (95% BCI 0.25-0.77)). There was no evidence of heterogeneity across disease. Our results support the use of total slope as a primary endpoint for clinical trials of CKD progression.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA.
| | - Willem Collier
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tom Greene
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Gerald B Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY, USA
| | - Sunil V Badve
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Benjamin Haaland
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Julia B Lewis
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Philip K T Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - Bart D Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Brendon L Neuen
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Renal Research Unit, Comprehensive Heart Failure Center, Department of Clinical Research and Epidemiology, University of Würzburg, Würzburg, Germany
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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22
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Heerspink HJL, Jongs N, Neuen BL, Schloemer P, Vaduganathan M, Inker LA, Fletcher RA, Wheeler DC, Bakris G, Greene T, Chertow GM, Perkovic V. Effects of newer kidney protective agents on kidney endpoints provide implications for future clinical trials. Kidney Int 2023; 104:181-188. [PMID: 37119876 DOI: 10.1016/j.kint.2023.03.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/02/2023] [Accepted: 03/24/2023] [Indexed: 05/01/2023]
Abstract
Doubling of serum creatinine (equivalent to a 57% decline in the estimated glomerular filtration rate (eGFR)) is an accepted component of a composite kidney endpoint in clinical trials. Smaller declines in eGFR (40%, 50%) have been applied in several recently conducted clinical trials. Here, we assessed the effects of newer kidney protective agents on endpoints including smaller proportional declines in eGFR to compare relative event rates and the magnitude of observed treatment effects. We performed a post hoc analysis of 4401 patients in the CREDENCE, 4304 in the DAPA-CKD, 5734 in the FIDELIO-DKD, and 3668 in the SONAR trials, which assessed the effects of canagliflozin, dapagliflozin, finerenone and atrasentan in patients with chronic kidney disease. Effects of active therapies versus placebo on alternative composite kidney endpoints incorporating different eGFR decline thresholds (40%, 50%, or 57% eGFR reductions from baseline) with kidney failure or death due to kidney failure were compared. Cox-proportional hazards regression models were used to assess and compare treatment effects. During follow-up, event rates were higher for endpoints incorporating smaller versus larger eGFR decline thresholds. Compared to the treatment effects on kidney failure or death due to kidney failure, the magnitude of relative treatment effects was generally similar when considering composite endpoints incorporating smaller declines in eGFR. Hazard ratios for the four interventions ranged from 0.63 to 0.82 for the endpoint incorporating 40% eGFR decline and 0.59 to 0.76 for the endpoint incorporating 57% eGFR decline. Clinical trials incorporating a 40% eGFR decline in a composite endpoint would require approximately half the number of participants compared to a 57% eGFR decline with equivalent statistical power. Thus, in populations at high risk of CKD progression, the relative effects of newer kidney protective therapies appear generally similar across endpoints based on varying eGFR decline thresholds.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; The George Institute for Global Health, Sydney, Australia.
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, Australia; Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | | | | | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - George Bakris
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Tom Greene
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah, USA
| | - Glenn M Chertow
- Department of Medicine, Epidemiology and Biostatistics, Stanford University School of Medicine, Stanford, California, USA; Department of Health Policy, Stanford University School of Medicine, Stanford, California, USA
| | - Vlado Perkovic
- Faculty of Medicine & Health, University New South Wales, Sydney, Australia
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23
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Fletcher RA, Arnott C, Rockenschaub P, Schutte AE, Carpenter L, Vaduganathan M, Agarwal R, Bakris G, Chang TI, Heerspink HJL, Jardine MJ, Mahaffey KW, Neal B, Pollock C, Jun M, Rodgers A, Perkovic V, Neuen BL. Canagliflozin, Blood Pressure Variability, and Risk of Cardiovascular, Kidney, and Mortality Outcomes: Pooled Individual Participant Data From the CANVAS and CREDENCE Trials. J Am Heart Assoc 2023:e028516. [PMID: 37345834 DOI: 10.1161/jaha.122.028516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Background Sodium glucose cotransporter-2 inhibitors reduce systolic blood pressure (SBP), but whether they affect SBP variability is unknown. There also remains uncertainty regarding the prognostic value of SBP variability for different clinical outcomes. Methods and Results Using individual participant data from the CANVAS (Canagliflozin Cardiovascular Assessment Study) Program and CREDENCE (Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation) trial, we assessed the effect of canagliflozin on SBP variability in people with type 2 diabetes across 4 study visits over 1.5 years as measured by standard deviation, coefficient of variation, and variability independent of the mean. We used multivariable Cox regression models to estimate associations of SBP variability with cardiovascular, kidney, and mortality outcomes. In 11 551 trial participants, canagliflozin modestly lowered the standard deviation of SBP variability (-0.25 mm Hg [95% CI, -0.44 to -0.06]), but there was no effect on coefficient of variation (0.02% [95% CI, -0.12 to 0.16]) or variability independent of the mean (0.08 U [95% CI, -0.11 to 0.26]) when adjusting for correlation with mean SBP. Each 1 standard deviation increase in standard deviation of SBP variability was independently associated with higher risk of hospitalization for heart failure (hazard ratio [HR], 1.19 [95% CI, 1.02-1.38]) and all-cause mortality (HR, 1.12 [95% CI, 1.01-1.25]), with consistent results observed for coefficient of variation and variability independent of the mean. Increases in SBP variability were not associated with kidney outcomes. Conclusions In people with type 2 diabetes at high cardiovascular risk or with chronic kidney disease, higher visit-to-visit SBP variability is independently associated with risks of hospitalization for heart failure and all-cause mortality. Canagliflozin has little to no effect on SBP variability, independent of its established SBP-lowering effect. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01032629, NCT01989754, NCT02065791.
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Affiliation(s)
- Robert A Fletcher
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Department of Cardiology Royal Prince Alfred Hospital New South Wales Sydney Australia
- Sydney Medical School University of Sydney New South Wales Australia
| | - Patrick Rockenschaub
- Charité Lab for Artificial Intelligence in Medicine Charité Universitätsmedizin Berlin Berlin Germany
- QUEST Center for Transforming Biomedical Research Berlin Institute of Health (BIH) Berlin Germany
| | - Aletta E Schutte
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Faculty of Medicine and Health UNSW New South Wales Sydney Australia
| | - Lewis Carpenter
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience King's College London London UK
| | | | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center IN Indianapolis USA
| | - George Bakris
- Department of Medicine University of Chicago Medicine IL Chicago USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine Stanford University School of Medicine CA Stanford USA
- Stanford Hypertension Center Stanford University School of Medicine CA Stanford USA
| | - Hiddo J L Heerspink
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Department of Clinical Pharmacy and Pharmacology University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - Meg J Jardine
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- NHMRC Clinical Trials Centre University of Sydney New South Wales Australia
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford Center for Clinical Research Stanford University School of Medicine CA Stanford USA
| | - Bruce Neal
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Imperial College London London UK
| | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School University of Sydney, Royal North Shore Hospital Sydney Australia
| | - Min Jun
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
| | - Anthony Rodgers
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience King's College London London UK
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW New South Wales Sydney Australia
- Department of Renal Medicine Royal North Shore Hospital New South Wales Sydney Australia
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24
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van der Hoek S, Jongs N, Oshima M, Neuen BL, Stevens J, Perkovic V, Levin A, Mahaffey KW, Pollock C, Greene T, Wheeler DC, Jardine MJ, Heerspink HJ. Glycemic Control and Effects of Canagliflozin in Reducing Albuminuria and eGFR: A Post Hoc Analysis of the CREDENCE Trial. Clin J Am Soc Nephrol 2023; 18:748-758. [PMID: 36999981 PMCID: PMC10278833 DOI: 10.2215/cjn.0000000000000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/17/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND In the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) trial, the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin improved kidney and cardiovascular outcomes and reduced the rate of estimated glomerular filtration decline (eGFR slope) in patients with type 2 diabetes and CKD. In other clinical trials of patients with CKD or heart failure, the protective effects of SGLT2 inhibitors on eGFR slope were greater in participants with versus participants without type 2 diabetes. This post hoc analysis of the CREDENCE trial assessed whether the effects of canagliflozin on eGFR slope varied according to patient subgroups by baseline glycated hemoglobin A1c (HbA1c). METHODS CREDENCE ( ClinicalTrials.gov [ NCT02065791 ]) was a randomized controlled trial in adults with type 2 diabetes with an HbA1c of 6.5%-12.0%, an eGFR of 30-90 ml/min per 1.73 m 2 , and a urinary albumin-to-creatinine ratio of 300-5000 mg/g. Participants were randomly assigned to canagliflozin 100 mg once daily or placebo. We studied the effect of canagliflozin on eGFR slope using linear mixed-effects models. RESULTS The annual difference in total eGFR slope was 1.52 ml/min per 1.73 m 2 (95% confidence interval [CI], 1.11 to 1.93) slower in participants randomized to canagliflozin compared with placebo. The rate of eGFR decline was faster in those with poorer baseline glycemic control. The mean difference in total eGFR slope between canagliflozin and placebo was greater in participants with poorer baseline glycemic control (difference in eGFR slope of 0.39, 1.36, 2.60, 1.63 ml/min per 1.73 m 2 for HbA1c subgroups 6.5%-7.0%, 7.0%-8.0%, 8.0%-10.0%, 10.0%-12.0%, respectively; Pinteraction = 0.010). The mean difference in change from baseline in urinary albumin-to-creatinine ratio between participants randomized to canagliflozin and placebo was smaller in patients with baseline HbA1c 6.5%-7.0% (-17% [95% CI, -28 to -5]) compared with those with an HbA1c of 7.0%-12% (-32% [95% CI, -40 to -28]; Pinteraction = 0.03). CONCLUSIONS The effect of canagliflozin on eGFR slope in patients with type 2 diabetes and CKD was more pronounced in patients with higher baseline HbA1c, partly because of the more rapid decline in kidney function in these individuals. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants With Diabetic Nephropathy (CREDENCE), NCT02065791.
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Affiliation(s)
- Sjoukje van der Hoek
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Brendon L. Neuen
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Jasper Stevens
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Vlado Perkovic
- Faculty of Medicine & Health, University New South Wales, Sydney, New South Wales, Australia
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Tom Greene
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah
| | - David C. Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Meg J. Jardine
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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25
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Sridhar VS, Neuen BL, Fletcher RA, Slee A, Ang FG, Rapattoni W, Arnott C, Cherney DZ, Perkovic V, Wheeler DC, Levin A. Kidney protection with canagliflozin: A combined analysis of the randomized CANVAS program and CREDENCE trials. Diabetes Obes Metab 2023. [PMID: 37184050 DOI: 10.1111/dom.15112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/16/2023]
Abstract
AIM In the CANVAS Program and CREDENCE trials, the sodium glucose co-transporter 2 inhibitor canagliflozin reduced the risk of cardiovascular and kidney events in patients with type 2 diabetes. The current study analysed a pooled population to ascertain the kidney protection provided by canagliflozin across the full spectrum of kidney parameters. METHODS This post-hoc pooled analysis of the CANVAS Program (N = 10 142) and CREDENCE trial (N = 4401), assessed the risk of the primary kidney composite (doubling of serum creatinine, end-stage kidney disease, renal death), in all patients and subgroups defined by baseline estimated glomerular filtration rate (<30, 30 to <45, 45 to <60 and ≥60 ml/min/1.73 m2 ), albuminuria [<30, 30-300, >300 mg/g (<3.39, 3.39-33.9, >33.9 mg/mmol)] and 2012 Kidney Disease: Improving Global Outcomes (KDIGO) classification of chronic kidney disease (low/moderate, high and very high risk). RESULTS In the overall population, the risk for the primary kidney composite outcome was 37% lower in the canagliflozin group versus placebo (HR: 0.63; 95% CI: 0.53, 0.77; p < .001). There was no evidence of heterogeneity in the kidney protective effects of canagliflozin across a range of kidney risks when stratified by baseline estimated glomerular filtration rate, albuminuria or KDIGO risk category (all pinteraction > .05). A statistically significant risk reduction of the primary kidney composite outcome was sustained by approximately 18 months after randomization. CONCLUSIONS These results emphasize a critical role of canagliflozin in kidney protection across a broad spectrum of participants with type 2 diabetes with varying levels of kidney function.
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Affiliation(s)
- Vikas S Sridhar
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Robert A Fletcher
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - April Slee
- New Arch Consulting, Seattle, Washington, USA
| | | | | | - Clare Arnott
- Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - David Z Cherney
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - David C Wheeler
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Centre for Nephrology, University College London, London, UK
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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26
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Kang A, Smyth B, Neuen BL, Heerspink HJL, Di Tanna GL, Zhang H, Arnott C, Hockham C, Agarwal R, Bakris G, Charytan DM, de Zeeuw D, Greene T, Levin A, Pollock C, Wheeler DC, Mahaffey KW, Perkovic V, Jardine MJ. The sodium-glucose cotransporter-2 inhibitor canagliflozin does not increase risk of non-genital skin and soft tissue infections in people with type 2 diabetes mellitus: A pooled post hoc analysis from the CANVAS Program and CREDENCE randomized double-blind trials. Diabetes Obes Metab 2023. [PMID: 37161691 DOI: 10.1111/dom.15091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/01/2023] [Accepted: 04/09/2023] [Indexed: 05/11/2023]
Abstract
AIMS To assess whether the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin affects risk of non-genital skin and soft tissue infections (SSTIs). MATERIALS AND METHODS We performed a post hoc pooled individual participant analysis of the CANVAS Program and CREDENCE trials that randomized people with type 2 diabetes at high cardiovascular risk and/or with chronic kidney disease to either canagliflozin or placebo. Investigator-reported adverse events were assessed by two blinded authors following predetermined criteria for non-genital SSTIs. Risks of non-genital SSTIs, overall and within prespecified subgroups, and risk of non-genital fungal SSTIs, were analysed using Cox regression models. Factors associated with non-genital SSTIs were assessed using multivariable Cox regression models. RESULTS Overall, 903 of 14 531 participants (6%) experienced non-genital SSTIs over a median follow-up of 26 months. No difference was observed in non-genital SSTI rates between canagliflozin and placebo (24.0 events/1000 person-years vs. 23.9 events/1000 person-years, respectively; hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.85-1.11; P = 0.70), with consistent results across subgroups (all P interaction > 0.05). The risk of recurrent events and non-genital fungal infection also did not differ significantly between canagliflozin and placebo (HR 1.06, 95% CI 0.94-1.19 [P = 0.32] and HR 1.18, 95% CI 0.88-1.60 [P = 0.27], respectively). Baseline factors independently associated with non-genital SSTIs were younger age, male sex, higher body mass index, higher glycated haemoglobin, lower estimated glomerular filtration rate (eGFR), established peripheral vascular disease, and history of neuropathy. CONCLUSIONS Canagliflozin did not affect risk of non-genital SSTIs or non-genital fungal SSTIs compared with placebo. These findings suggest that any SGLT2 inhibitor-mediated change in skin microenvironment is unlikely to have meaningful clinical consequences.
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Affiliation(s)
- Amy Kang
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
- Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Brendan Smyth
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Renal Medicine, St George Hospital, Sydney, New South Wales, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Hong Zhang
- Renal Division of Peking University First Hospital, Beijing, China
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney Medical School, Sydney, New South Wales, Australia
| | - Carinna Hockham
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, Indianapolis, Indiana, USA
| | - George Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - David M Charytan
- Nephrology Division, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Tom Greene
- University of Utah, Salt Lake City, Utah, USA
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - David C Wheeler
- Department of Renal Medicine, University College London Medical School, London, UK
| | - Kenneth W Mahaffey
- Stanford Centre for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Meg J Jardine
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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27
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Neuen BL, Kennedy S. Biomarkers and personalised medicine in paediatric kidney disease. Lancet Child Adolesc Health 2023; 7:369-371. [PMID: 37119828 DOI: 10.1016/s2352-4642(23)00102-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042, Australia; Department of Renal Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia.
| | - Sean Kennedy
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2042, Australia; Department of Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia
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28
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Yi TW, Wong MMY, Neuen BL, Arnott C, Poirier P, Seufert J, Slee A, Rapattoni W, Ang FG, Wheeler DC, Mahaffey KW, Perkovic V, Levin A. Effects of canagliflozin on cardiovascular and kidney events in patients with chronic kidney disease with and without peripheral arterial disease: integrated analysis from the CANVAS Program and CREDENCE trial. Diabetes Obes Metab 2023. [PMID: 36974373 DOI: 10.1111/dom.15065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Tae Won Yi
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michelle M Y Wong
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Faculty of Medicine, UNSW Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Australia
| | - Paul Poirier
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | | | | | - David C Wheeler
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Centre for Nephrology, University College London, London, UK
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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29
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Tsoukas MA, Woo V, Tobe SW, Slee A, Rapattoni W, Ang FG, Seufert J, Neuen BL, Arnott C, Mahaffey KW, Wheeler DC. Cardiovascular and kidney outcomes with canagliflozin according to type 2 diabetes treatment targets at baseline: Data from the CANVAS Program and CREDENCE. Diabetes Obes Metab 2023. [PMID: 36942888 DOI: 10.1111/dom.15057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Affiliation(s)
| | - Vincent Woo
- University of Manitoba, Winnipeg, MB, Canada
| | - Sheldon W Tobe
- Sunnybrook Research Institute, Toronto, ON, Canada
- Northern Ontario School of Medicine, Sudbury, ON, Canada
| | | | | | | | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia
- Faculty of Medicine, UNSW Sydney, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - David C Wheeler
- Centre for Nephrology, University College London, London, UK
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30
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Tye S, Oshima M, Arnott C, Neuen BL, Fletcher RA, Neal B, Heerspink HJL. The importance of targeting multiple risk markers in patients with type 2 diabetes: A post-hoc study from the CANVAS programme. Diabetes Obes Metab 2023; 25:1638-1645. [PMID: 36782264 DOI: 10.1111/dom.15018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023]
Abstract
AIMS To investigate the extent to which improvements in multiple cardiovascular risk markers are associated with a lower risk of cardiovascular and kidney outcomes in patients with type 2 diabetes and high cardiovascular risk participating in the CANVAS programme. MATERIALS AND METHODS Clinically relevant improvements in cardiovascular risk factors were defined as a reduction in glycated haemoglobin ≥1.0%, systolic blood pressure ≥10 mmHg, body weight ≥3 kg, urinary-albumin-creatinine ratio ≥30%, uric acid ≥0.5 mg/dl, and an increase in haemoglobin of ≥1.0 g/dl from baseline to week 26. Participants were categorized according to the number of improvements in cardiovascular risk markers: zero, one, two, three, or four or more risk marker improvements. The Cox proportional hazard regression adjusted for treatment assignment, demographic variables and laboratory measurements was performed to determine the association between the number of risk marker improvements and risk of a composite cardiovascular, heart failure or kidney outcomes. RESULTS We included 9487 (93.5%) participants with available data at baseline and week 26. After week 26, 566 composite cardiovascular, 370 heart failure/cardiovascular death and 153 composite kidney outcomes occurred. The multivariable adjusted hazard ratios associated with four or more improvements in risk markers versus no risk marker improvement were 0.67 (95% CI 0.48, 0.92), 0.58 (95% CI 0.39, 0.87) and 0.49 (95% CI 0.25, 0.96) for the three outcomes respectively. We observed a trend of decreased hazard ratios across subgroups of increasing number of risk marker improvements (p for trend = .008, .02 and .047, respectively). CONCLUSIONS In patients with type 2 diabetes, improvements in multiple risk markers were associated with a reduced risk of cardiovascular and kidney outcomes as compared with no risk marker improvement.
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Affiliation(s)
- SokCin Tye
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Robert A Fletcher
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, 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, UNSW Sydney, Sydney, New South Wales, Australia
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31
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Collier W, Inker LA, Haaland B, Appel GB, Badve SV, Caravaca-Fontán F, Chalmers J, Floege J, Goicoechea M, Imai E, Jafar TH, Lewis JB, Li PK, Locatelli F, Maes BD, Neuen BL, Perrone RD, Remuzzi G, Schena FP, Wanner C, Heerspink HJ, Greene T. Evaluation of Variation in the Performance of GFR Slope as a Surrogate End Point for Kidney Failure in Clinical Trials that Differ by Severity of CKD. Clin J Am Soc Nephrol 2023; 18:183-192. [PMID: 36754007 PMCID: PMC10103374 DOI: 10.2215/cjn.0000000000000050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/02/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The GFR slope has been evaluated as a surrogate end point for kidney failure in meta-analyses on a broad collection of randomized controlled trials (RCTs) in CKD. These analyses evaluate how accurately a treatment effect on GFR slope predicts a treatment effect on kidney failure. We sought to determine whether severity of CKD in the patient population modifies the performance of GFR slope. METHODS We performed Bayesian meta-regression analyses on 66 CKD RCTs to evaluate associations between effects on GFR slope (the chronic slope and the total slope over 3 years, expressed as mean differences in ml/min per 1.73 m2/yr) and those of the clinical end point (doubling of serum creatinine, GFR <15 ml/min per 1.73 m2, or kidney failure, expressed as a log-hazard ratio), where models allow interaction with variables defining disease severity. We evaluated three measures (baseline GFR in 10 ml/min per 1.73 m2, baseline urine albumin-to-creatinine ratio [UACR] per doubling in mg/g, and CKD progression rate defined as the control arm chronic slope, in ml/min per 1.73 m2/yr) and defined strong evidence for modification when 95% posterior credible intervals for interaction terms excluded zero. RESULTS There was no evidence for modification by disease severity when evaluating 3-year total slope (95% credible intervals for the interaction slope: baseline GFR [-0.05 to 0.03]; baseline UACR [-0.02 to 0.04]; CKD progression rate [-0.07 to 0.02]). There was strong evidence for modification in evaluations of chronic slope (95% credible intervals: baseline GFR [0.02 to 0.11]; baseline UACR [-0.11 to -0.02]; CKD progression rate [0.01 to 0.15]). CONCLUSIONS These analyses indicate consistency of the performance of total slope over 3 years, which provides further evidence for its validity as a surrogate end point in RCTs representing varied CKD populations.
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Affiliation(s)
- Willem Collier
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin Haaland
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Gerald B. Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York
| | - Sunil V. Badve
- Renal and Metabolic Division, the George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - John Chalmers
- Renal and Metabolic Division, the George Institute for Global Health, Newtown, New South Wales, Australia
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Julia B. Lewis
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Philip K.T. Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Francesco Locatelli
- Department of Nephrology, Alessandro Manzoni Hospital (past Director), ASST Lecco, Italy
| | - Bart D. Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Brendon L. Neuen
- Renal and Metabolic Division, the George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P. Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tom Greene
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
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32
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Koshino A, Oshima M, Arnott C, Fletcher RA, Bakris GL, Jardine M, Mahaffey KW, Perkovic V, Pollock C, Heerspink HJL, Neuen BL. Effects of canagliflozin on liver steatosis and fibrosis markers in patients with type 2 diabetes and chronic kidney disease: A post hoc analysis of the CREDENCE trial. Diabetes Obes Metab 2023; 25:1413-1418. [PMID: 36655422 DOI: 10.1111/dom.14978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Affiliation(s)
- Akihiko Koshino
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
- The George Institute for Global Health, UNSW, Sydney, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW, Sydney, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - George L Bakris
- Department of Medicine, AHA Comprehensive Hypertension Center University of Chicago Medicine, Chicago, Illinois, USA
| | - Meg Jardine
- The George Institute for Global Health, UNSW, Sydney, Australia
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Australia
- Concord Repatriation General Hospital, Sydney, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, California, USA
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, Australia
- Royal North Shore Hospital, St Leonards, 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, UNSW, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW, Sydney, Australia
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33
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Neuen BL, Bello AK, Levin A, Lunney M, Osman MA, Ye F, Ashuntantang GE, Bellorin-Font E, Gharbi MB, Davison S, Ghnaimat M, Harden P, Jha V, Kalantar-Zadeh K, Kerr PG, Klarenbach S, Kovesdy CP, Luyckx V, Ossareh S, Perl J, Rashid HU, Rondeau E, See EJ, Saad S, Sola L, Tchokhonelidze I, Tesar V, Tungsanga K, Kazancioglu RT, Wang AYM, Yang CW, Zemchenkov A, Zhao MH, Jager KJ, Caskey FJ, Perkovic V, Jindal KK, Okpechi IG, Tonelli M, Feehally J, Harris DC, Johnson DW. National health policies and strategies for addressing chronic kidney disease: Data from the International Society of Nephrology Global Kidney Health Atlas. PLOS Glob Public Health 2023; 3:e0001467. [PMID: 36963092 PMCID: PMC10021302 DOI: 10.1371/journal.pgph.0001467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/14/2022] [Indexed: 02/04/2023]
Abstract
National strategies for addressing chronic kidney disease (CKD) are crucial to improving kidney health. We sought to describe country-level variations in non-communicable disease (NCD) strategies and CKD-specific policies across different regions and income levels worldwide. The International Society of Nephrology Global Kidney Health Atlas (GKHA) was a multinational cross-sectional survey conducted between July and October 2018. Responses from key opinion leaders in each country regarding national NCD strategies, the presence and scope of CKD-specific policies, and government recognition of CKD as a health priority were described overall and according to region and income level. 160 countries participated in the GKHA survey, comprising 97.8% of the world's population. Seventy-four (47%) countries had an established national NCD strategy, and 53 (34%) countries reported the existence of CKD-specific policies, with substantial variation across regions and income levels. Where CKD-specific policies existed, non-dialysis CKD care was variably addressed. 79 (51%) countries identified government recognition of CKD as a health priority. Low- and low-middle income countries were less likely to have strategies and policies for addressing CKD and have governments which recognise it as a health priority. The existence of CKD-specific policies, and a national NCD strategy more broadly, varied substantially across different regions around the world but was overall suboptimal, with major discrepancies between the burden of CKD in many countries and governmental recognition of CKD as a health priority. Greater recognition of CKD within national health policy is critical to improving kidney healthcare globally.
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Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Aminu K Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Meaghan Lunney
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Mohamed A Osman
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Feng Ye
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Gloria E Ashuntantang
- Faculty of Medicine and Biomedical Sciences, Yaounde General Hospital, University of Yaounde, Yaounde, Cameroon
| | - Ezequiel Bellorin-Font
- Division of Nephology and Hypertension, Department of Medicine, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Mohammed Benghanem Gharbi
- Urinary Tract Diseases Department, Faculty of Medicine and Pharmacy of Casablanca, University Hassan II of Casablanca, Casablanca, Morocco
| | - Sara Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Mohammad Ghnaimat
- Nephrology Division, Department of Internal Medicine, The Specialty Hospital, Amman, Jordan
| | - Paul Harden
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi, India
- School of Public Health, Imperial College, London, United Kingdom
- Manipal Academy of Higher Education, Manipal, India
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, United States of America
| | - Peter G Kerr
- Department of Medicine, Monash University, Melbourne, Australia
| | - Scott Klarenbach
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Csaba P Kovesdy
- University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
| | - Valerie Luyckx
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Shahrzad Ossareh
- Division of Nephrology, Department of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Harun Ur Rashid
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - Eric Rondeau
- Intensive Care Nephrology and Transplantation Department, Hopital Tenon, Assistance Publique-Hopitaux de Paris, Paris, France
- Sorbonne Université, Paris, France
| | - Emily J See
- Department of Intensive Care, Austin Health, Melbourne, Australia
- School of Medicine, University of Melbourne, Melbourne, Australia
| | - Syed Saad
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Laura Sola
- Dialysis Unit, CASMU-IAMPP, Montevideo, Uruguay
| | - Irma Tchokhonelidze
- Nephrology Development Clinical Center, Tbilisi State Medical University, Tbilisi, Georgia
| | - Vladimir Tesar
- Department of Nephrology, General University Hospital, Charles University, Prague, Czech Republic
| | - Kriang Tungsanga
- Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | | | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Alexander Zemchenkov
- Department of Internal Disease and Nephrology, North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
- Department of Nephrology and Dialysis, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Key Lab of Renal Disease, Ministry of Health of China, Beijing, China
- Key Lab of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China; Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Kitty J Jager
- ERA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
- The Richard Bright Renal Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Kailash K Jindal
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ikechi G Okpechi
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Canada
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Canada
- Pan-American Health Organization/World Health Organization's Collaborating Centre in Prevention and Control of Chronic Kidney Disease, University of Calgary, Calgary, Canada
| | | | - David C Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, Australia
| | - David W Johnson
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Metro South and Ipswich Nephrology and Transplant Services (MINTS), Princess Alexandra Hospital, Brisbane, Australia
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Baigent C, Emberson J, Haynes R, Herrington WG, Judge P, Landray MJ, Mayne KJ, Ng SY, Preiss D, Roddick AJ, Staplin N, Zhu D, Anker SD, Bhatt DL, Brueckmann M, Butler J, Cherney DZ, Green JB, Hauske SJ, Haynes R, Heerspink HJ, Herrington WG, Inzucchi SE, Jardine MJ, Liu CC, Mahaffey KW, McCausland FR, McGuire DK, McMurray JJ, Neal B, Neuen BL, Packer M, Perkovic V, Sabatine MS, Solomon SD, Vaduganathan M, Wanner C, Wheeler DC, Wiviott SD, Zannad F. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet 2022; 400:1788-1801. [PMID: 36351458 PMCID: PMC7613836 DOI: 10.1016/s0140-6736(22)02074-8] [Citation(s) in RCA: 200] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Large trials have shown that sodium glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of adverse kidney and cardiovascular outcomes in patients with heart failure or chronic kidney disease, or with type 2 diabetes and high risk of atherosclerotic cardiovascular disease. None of the trials recruiting patients with and without diabetes were designed to assess outcomes separately in patients without diabetes. METHODS We did a systematic review and meta-analysis of SGLT2 inhibitor trials. We searched the MEDLINE and Embase databases for trials published from database inception to Sept 5, 2022. SGLT2 inhibitor trials that were double-blind, placebo-controlled, performed in adults (age ≥18 years), large (≥500 participants per group), and at least 6 months in duration were included. Summary-level data used for analysis were extracted from published reports or provided by trial investigators, and inverse-variance-weighted meta-analyses were conducted to estimate treatment effects. The main efficacy outcomes were kidney disease progression (standardised to a definition of a sustained ≥50% decrease in estimated glomerular filtration rate [eGFR] from randomisation, a sustained low eGFR, end-stage kidney disease, or death from kidney failure), acute kidney injury, and a composite of cardiovascular death or hospitalisation for heart failure. Other outcomes were death from cardiovascular and non-cardiovascular disease considered separately, and the main safety outcomes were ketoacidosis and lower limb amputation. This study is registered with PROSPERO, CRD42022351618. FINDINGS We identified 13 trials involving 90 413 participants. After exclusion of four participants with uncertain diabetes status, we analysed 90 409 participants (74 804 [82·7%] participants with diabetes [>99% with type 2 diabetes] and 15 605 [17·3%] without diabetes; trial-level mean baseline eGFR range 37-85 mL/min per 1·73 m2). Compared with placebo, allocation to an SGLT2 inhibitor reduced the risk of kidney disease progression by 37% (relative risk [RR] 0·63, 95% CI 0·58-0·69) with similar RRs in patients with and without diabetes. In the four chronic kidney disease trials, RRs were similar irrespective of primary kidney diagnosis. SGLT2 inhibitors reduced the risk of acute kidney injury by 23% (0·77, 0·70-0·84) and the risk of cardiovascular death or hospitalisation for heart failure by 23% (0·77, 0·74-0·81), again with similar effects in those with and without diabetes. SGLT2 inhibitors also reduced the risk of cardiovascular death (0·86, 0·81-0·92) but did not significantly reduce the risk of non-cardiovascular death (0·94, 0·88-1·02). For these mortality outcomes, RRs were similar in patients with and without diabetes. For all outcomes, results were broadly similar irrespective of trial mean baseline eGFR. Based on estimates of absolute effects, the absolute benefits of SGLT2 inhibition outweighed any serious hazards of ketoacidosis or amputation. INTERPRETATION In addition to the established cardiovascular benefits of SGLT2 inhibitors, the randomised data support their use for modifying risk of kidney disease progression and acute kidney injury, not only in patients with type 2 diabetes at high cardiovascular risk, but also in patients with chronic kidney disease or heart failure irrespective of diabetes status, primary kidney disease, or kidney function. FUNDING UK Medical Research Council and Kidney Research UK.
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Koshino A, Schechter M, Sen T, Vart P, Neuen BL, Neal B, Arnott C, Perkovic V, Ridker PM, Tuttle KR, Hansen MK, Heerspink HJL. Interleukin-6 and Cardiovascular and Kidney Outcomes in Patients With Type 2 Diabetes: New Insights From CANVAS. Diabetes Care 2022; 45:2644-2652. [PMID: 36134918 PMCID: PMC9862371 DOI: 10.2337/dc22-0866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/11/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The inflammatory cytokine interleukin-6 (IL-6) is associated with cardiovascular (CV) and kidney outcomes in various populations. However, data in patients with type 2 diabetes are limited. We assessed the association of IL-6 with CV and kidney outcomes in the Canagliflozin Cardiovascular Assessment Study (CANVAS) and determined the effect of canagliflozin on IL-6. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes at high CV risk were randomly assigned to canagliflozin or placebo. Plasma IL-6 was measured at baseline and years 1, 3, and 6. The composite CV outcome was nonfatal myocardial infarction, nonfatal stroke, or CV death; the composite kidney outcome was sustained ≥40% estimated glomerular filtration rate decline, end-stage kidney disease, or kidney-related death. Multivariable-adjusted Cox proportional hazards regression was used to estimate the associations between IL-6 and the outcomes. The effect of canagliflozin on IL-6 over time was assessed with a repeated-measures mixed-effects model. RESULTS The geometric mean IL-6 at baseline, available in 3,503 (80.2%) participants, was 1.7 pg/mL. Each doubling of baseline IL-6 was associated with 14% (95% CI 4, 24) and 21% (95% CI 1, 45) increased risk of CV and kidney outcomes, respectively. Over 6 years, IL-6 increased by 5.8% (95% CI 3.4, 8.3) in the placebo group. Canagliflozin modestly attenuated the IL-6 increase (absolute percentage difference vs. placebo 4.4% [95% CI 1.3, 9.9; P = 0.01]). At year 1, each 25% lower level of IL-6 compared with baseline was associated with 7% (95% CI 1, 22) and 14% (95% CI 5, 22) lower risks for the CV and kidney outcome, respectively. CONCLUSIONS In patients with type 2 diabetes at high CV risk, baseline IL-6 and its 1-year change were associated with CV and kidney outcomes. The effect of IL-6-lowering therapy on CV, kidney, and safety outcomes remains to be tested.
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Affiliation(s)
- Akihiko Koshino
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Meir Schechter
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Taha Sen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Bruce Neal
- The George Institute for Global Health, Sydney, Australia
| | - Clare Arnott
- The George Institute for Global Health, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Paul M Ridker
- Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, and Nephrology Division, University of Washington, Spokane, WA
| | | | - 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.,University of New South Wales, Sydney, Australia
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36
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Li C, Yu J, Hockham C, Perkovic V, Neuen BL, Badve SV, Houston L, Lee VYJ, Barraclough JY, Fletcher RA, Mahaffey KW, Heerspink HJL, Cannon CP, Neal B, Arnott C. Canagliflozin and atrial fibrillation in type 2 diabetes mellitus: A secondary analysis from the CANVAS Program and CREDENCE trial and meta-analysis. Diabetes Obes Metab 2022; 24:1927-1938. [PMID: 35589614 DOI: 10.1111/dom.14772] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/07/2022] [Accepted: 05/17/2022] [Indexed: 01/10/2023]
Abstract
AIM To assess the effects of canagliflozin on the incidence of atrial fibrillation/atrial flutter (AF/AFL) and other key cardiorenal outcomes in a pooled analysis of the CANVAS and CREDENCE trials. MATERIALS AND METHODS Participants with type 2 diabetes and high risk of cardiovascular disease or chronic kidney disease were included and randomly assigned to canagliflozin or placebo. We explored the effects of canagliflozin on the incidence of first AF/AFL events and AF/AFL-related complications (ischaemic stroke/transient ischaemic attack/hospitalization for heart failure). Major adverse cardiovascular events and a renal-specific outcome by baseline AF/AFL status were analysed using Cox regression models. RESULTS Overall, 354 participants experienced a first AF/AFL event. Canagliflozin had no detectable effect on AF/AFL (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.67-1.02) compared with placebo. Subgroup analysis, however, suggested a possible reduction in AF/AFL in those with no AF/AFL history (HR 0.78, 95% CI 0.62-0.99). Canagliflozin was also associated with a reduction in AF/AFL-related complications (HR 0.74, 95% CI 0.65-0.86). There was no evidence of treatment heterogeneity by baseline AF/AFL history for other key cardiorenal outcomes (all Pinteraction > 0.14). Meta-analysis of five sodium-glucose cotransporter-2 (SGLT2) inhibitor trials demonstrated a 19% reduction in AF/AFL events with active treatment (HR 0.81, 95% CI 0.72-0.92). CONCLUSIONS Overall, a significant effect of canagliflozin on the incidence of AF/AFL events could not be shown, however, a possible reduction in AF/AFL events in those with no prior history requires further investigation. Meta-analysis suggests SGLT2 inhibition reduces AF/AFL incidence.
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Affiliation(s)
- Chao Li
- Cardiovascular Centre, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jie Yu
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Carinna Hockham
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sunil V Badve
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Nephrology, St George Hospital, Sydney, Australia
| | - Lauren Houston
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Vivian Y J Lee
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Robert A Fletcher
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Hiddo J L Heerspink
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christopher P Cannon
- Cardiovascular Division, Brigham & Women's Hospital and Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Imperial College London, London, UK
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Vaduganathan M, Ferreira JP, Rossignol P, Neuen BL, Claggett BL, Pfeffer MA, McMurray JJV, Pitt B, Zannad F, Solomon SD. Effects of Steroidal Mineralocorticoid Receptor Antagonists on Acute and Chronic Estimated Glomerular Filtration Rate Slopes in Patients with Chronic Heart Failure. Eur J Heart Fail 2022; 24:1586-1590. [PMID: 35867859 DOI: 10.1002/ejhf.2635] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS Steroidal mineralocorticoid receptor antagonists (MRAs) form a cornerstone of the management of heart failure (HF), but little is known about the long-term effects of MRA therapy on kidney function. We evaluated acute and chronic estimated glomerular function (eGFR) slopes in the 2 largest completed trials testing steroidal MRAs in chronic HF. METHODS AND RESULTS We conducted parallel post hoc eGFR slope analyses in 2 multinational, double-blind randomized, placebo-controlled trials of steroidal MRAs in chronic HF with reduced ejection fraction (EMPHASIS-HF) and preserved ejection fraction (TOPCAT Americas region). GFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation. Annual slopes of eGFR were assessed by generalized random coefficient models. Least square mean differences of eGFR slopes between steroidal MRA and placebo arms. Median follow-up was 1.8 years (EMPHASIS-HF) and 3.3 years (TOPCAT Americas). From baseline to month 4-6 ("acute eGFR slope"), compared to placebo, MRA treatment led to an acute decline in eGFR of -2.4 mL/min/1.73m2 (95% CI -3.4 to -1.4; P <0.001) and -2.0 mL/min/1.73m2 (95% CI -3.0 to -1.8; P <0.001) in EMPHASIS-HF and TOPCAT Americas, respectively. From month 4-6 to end of study, there was no difference in "chronic eGFR slope" between MRA and placebo arms (-0.3 mL/min/1.73m2 /year [95% CI -1.3 to 0.7; P =0.53] and 0.1 mL/min/1.73m2 /year [95% CI -1.4 to 1.7; P =0.86]) in EMPHASIS-HF and TOPCAT Americas, respectively. CONCLUSIONS Steroidal MRAs result in acute declines in eGFR but do not modify long-term kidney disease trajectories in chronic HF with reduced or preserved ejection fraction. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - João Pedro Ferreira
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Nancy, France
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Patrick Rossignol
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Nancy, France
- Department of Medical specialties and Nephrology-Hemodialysis, Princess Grace Hospital, Monaco, and Centre d'Hémodialyse Privé de Monaco, Monaco
| | - Brendon L Neuen
- George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Nancy, France
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Neuen BL, Inker LA, Vaduganathan M. Endothelin Receptor Antagonists and Risk of Heart Failure in CKD: Balancing the Cardiorenal Axis. JACC Heart Fail 2022; 10:508-511. [PMID: 35772862 DOI: 10.1016/j.jchf.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Brendon L Neuen
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia.
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Barraclough JY, Yu J, Figtree GA, Perkovic V, Heerspink HJL, Neuen BL, Cannon CP, Mahaffey KW, Schutte AE, Neal B, Arnott C. Cardiovascular and renal outcomes with canagliflozin in patients with peripheral arterial disease: Data from the CANVAS Program and CREDENCE trial. Diabetes Obes Metab 2022; 24:1072-1083. [PMID: 35166429 DOI: 10.1111/dom.14671] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/02/2022] [Accepted: 02/11/2022] [Indexed: 01/10/2023]
Abstract
AIM To define the proportional and absolute benefits of the sodium-glucose co-transporter-2 inhibitor canagliflozin in patients with type 2 diabetes (T2D) with and without peripheral arterial disease (PAD). MATERIALS AND METHODS We pooled individual participant data from the CANVAS Program (n = 10 142) and CREDENCE trial (n = 4401). In this post hoc analysis, the main outcomes of interest were major adverse cardiovascular events (MACE: non-fatal myocardial infarction, non-fatal stroke or cardiovascular death), kidney outcomes, and extended major adverse limb events (MALE). Cox proportional hazards models were used to assess canagliflozin treatment effects in those with and without PAD. Absolute risk reductions per 1000 patients treated for 2.5 years were estimated using Poisson regression. RESULTS Of 14 543 participants, 3159 (21.7%) had PAD at baseline. In patients with PAD, canagliflozin reduced MACE (hazard ratio, 0.76; 95% confidence interval, 0.62-0.92), with similar relative benefits for other cardiovascular and kidney outcomes in participants with or without PAD at baseline (all Pinteraction > .268). There was no increase in the relative risk of extended MALE with canagliflozin, irrespective of baseline PAD history (Pinteraction > .864). The absolute benefits of canagliflozin were greater in those with PAD. CONCLUSIONS Patients with T2D and PAD derived similar relative cardiorenal benefits from canagliflozin treatment but higher absolute benefits compared with those without PAD, with no increase in extended MALE.
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Affiliation(s)
- Jennifer Y Barraclough
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jie Yu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Gemma A Figtree
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Kolling Institute, Royal North Shore Hospital and University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Aletta E Schutte
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- The Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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40
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Neuen BL, Oshima M, Agarwal R, Arnott C, Cherney DZ, Edwards R, Langkilde AM, Mahaffey KW, McGuire DK, Neal B, Perkovic V, Pong A, Sabatine MS, Raz I, Toyama T, Wanner C, Wheeler DC, Wiviott SD, Zinman B, Heerspink HJL. Sodium-Glucose Cotransporter 2 Inhibitors and Risk of Hyperkalemia in People With Type 2 Diabetes: A Meta-Analysis of Individual Participant Data From Randomized, Controlled Trials. Circulation 2022; 145:1460-1470. [PMID: 35394821 DOI: 10.1161/circulationaha.121.057736] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperkalemia increases risk of cardiac arrhythmias and death and limits the use of renin-angiotensin-aldosterone system inhibitors and mineralocorticoid receptor antagonists, which improve clinical outcomes in people with chronic kidney disease or systolic heart failure. Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of cardiorenal events in people with type 2 diabetes at high cardiovascular risk or with chronic kidney disease. However, their effect on hyperkalemia has not been systematically evaluated. METHODS A meta-analysis was conducted using individual participant data from randomized, double-blind, placebo-controlled clinical outcome trials with SGLT2 inhibitors in people with type 2 diabetes at high cardiovascular risk or with chronic kidney disease in whom serum potassium levels were routinely measured. The primary outcome was time to serious hyperkalemia, defined as central laboratory-determined serum potassium ≥6.0 mmol/L, with other outcomes including investigator-reported hyperkalemia events and hypokalemia (serum potassium ≤3.5 mmol/L). Cox regression analyses were performed to estimate treatment effects from each trial with hazards ratios and corresponding 95% CIs pooled with random-effects models to obtain summary treatment effects, overall and across key subgroups. RESULTS Results from 6 trials were included comprising 49 875 participants assessing 4 SGLT2 inhibitors. Of these, 1754 participants developed serious hyperkalemia, and an additional 1119 investigator-reported hyperkalemia events were recorded. SGLT2 inhibitors reduced the risk of serious hyperkalemia (hazard ratio, 0.84 [95% CI, 0.76-0.93]), an effect consistent across studies (Pheterogeneity=0.71). The incidence of investigator-reported hyperkalemia was also lower with SGLT2 inhibitors (hazard ratio, 0.80 [95% CI, 0.68-0.93]; Pheterogeneity=0.21). Reductions in serious hyperkalemia were observed across a range of subgroups, including baseline kidney function, history of heart failure, and use of renin-angiotensin-aldosterone system inhibitor, diuretic, and mineralocorticoid receptor antagonist. SGLT2 inhibitors did not increase the risk of hypokalemia (hazard ratio, 1.04 [95% CI, 0.94-1.15]; Pheterogeneity=0.42). CONCLUSIONS SGLT2 inhibitors reduce the risk of serious hyperkalemia in people with type 2 diabetes at high cardiovascular risk or with chronic kidney disease without increasing the risk of hypokalemia.
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Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., C.A.)
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Japan (M.O., T.T.)
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, Indianapolis (R.A.)
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., C.A.).,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.A.).,Sydney Medical School, University of Sydney, Australia (C.A.)
| | - David Z Cherney
- Department of Medicine and Department of Physiology, Division of Nephrology, University Health Network, University of Toronto, Ontario, Canada (D.Z.C.)
| | | | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Darren K McGuire
- Department of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas (D.K.M.)
| | - Bruce Neal
- The Charles Perkins Centre, University of Sydney, Australia (B.N.).,Department of Epidemiology and Biostatistics, Imperial College London, UK (B.N.)
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales, Sydney, Australia (V.P.)
| | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (M.S.S., S.D.W.)
| | - Itamar Raz
- Diabetes Unit, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel (I.R.)
| | | | - Christoph Wanner
- Division of Nephrology, Department of Medicine, Würzburg University Clinic, Germany (C.W.)
| | - David C Wheeler
- Department of Renal Medicine, UCL Medical School, London, UK (D.C.W.)
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (M.S.S., S.D.W.)
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Ontario, Canada (B.Z.)
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, the Netherlands (H.J.L.H.)
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Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Meg J Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia.,Concord Repatriation General Hospital, Sydney, Australia
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Waijer SW, Sen T, Arnott C, Neal B, Kosterink JG, Mahaffey KW, Parikh CR, de Zeeuw D, Perkovic V, Neuen BL, Coca SG, Hansen MK, Gansevoort RT, Heerspink HJ. Association between TNF Receptors and KIM-1 with Kidney Outcomes in Early-Stage Diabetic Kidney Disease. Clin J Am Soc Nephrol 2022; 17:251-259. [PMID: 34876454 PMCID: PMC8823939 DOI: 10.2215/cjn.08780621] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Clinical trials in nephrology are enriched for patients with micro- or macroalbuminuria to enroll patients at risk of kidney failure. However, patients with normoalbuminuria can also progress to kidney failure. TNF receptor-1, TNF receptor-2, and kidney injury marker-1 (KIM-1) are known to be associated with kidney disease progression in patients with micro- or macroalbuminuria. We assessed the value of TNF receptor-1, TNF receptor-2, and KIM-1 as prognostic biomarkers for CKD progression in patients with type 2 diabetes and normoalbuminuria. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS TNF receptor-1, TNF receptor-2, and KIM-1 were measured using immunoassays in plasma samples from patients with type 2 diabetes at high cardiovascular risk participating in the Canagliflozin Cardiovascular Assessment Study trial. We used multivariable adjusted Cox proportional hazards analyses to estimate hazard ratios per doubling of each biomarker for the kidney outcome, stratified the population by the fourth quartile of each biomarker distribution, and assessed the number of events and event rates. RESULTS In patients with normoalbuminuria (n=2553), 51 kidney outcomes were recorded during a median follow-up of 6.1 (interquartile range, 5.8-6.4) years (event rate, 3.5; 95% confidence interval, 2.6 to 4.6 per 1000 patient-years). Each doubling of baseline TNF receptor-1 (hazard ratio, 4.2; 95% confidence interval, 1.8 to 9.6) and TNF receptor-2 (hazard ratio, 2.3; 95% confidence interval, 1.5 to 3.6) was associated with a higher risk for the kidney outcome. Baseline KIM-1, urinary albumin-creatinine ratio, and eGFR were not associated with kidney outcomes. The event rates in the highest quartile of TNF receptor-1 (≥2992 ng/ml) and TNF receptor-2 (≥11,394 ng/ml) were 5.6 and 7.0 events per 1000 patient-years, respectively, compared with 2.8 and 2.3, respectively, in the lower three quartiles. CONCLUSIONS TNF receptor-1 and TNF receptor-2 are associated with kidney outcomes in patients with type 2 diabetes and normoalbuminuria. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER CANagliflozin cardioVascular Assessment Study (CANVAS), NCT01032629.
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Affiliation(s)
- Simke W. Waijer
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Taha Sen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, New South Wales, Australia,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Jos G.W. Kosterink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands,Department of PharmacoTherapy, Epidemiology and Economics, University of Groningen, Groningen, The Netherlands
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Chirag R. Parikh
- Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Brendon L. Neuen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Steven G. Coca
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Ron T. Gansevoort
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - 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, University of New South Wales Sydney, Sydney, New South Wales, Australia
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Neuen BL, Tighiouart H, Heerspink HJ, Vonesh EF, Chaudhari J, Miao S, Chan TM, Fervenza FC, Floege J, Goicoechea M, Herrington WG, Imai E, Jafar TH, Lewis JB, Li PKT, Locatelli F, Maes BD, Perrone RD, Praga M, Perna A, Schena FP, Wanner C, Wetzels JF, Woodward M, Xie D, Greene T, Inker LA. Acute Treatment Effects on GFR in Randomized Clinical Trials of Kidney Disease Progression. J Am Soc Nephrol 2022; 33:291-303. [PMID: 34862238 PMCID: PMC8819983 DOI: 10.1681/asn.2021070948] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/28/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Acute changes in GFR can occur after initiation of interventions targeting progression of CKD. These acute changes complicate the interpretation of long-term treatment effects. METHODS To assess the magnitude and consistency of acute effects in randomized clinical trials and explore factors that might affect them, we performed a meta-analysis of 53 randomized clinical trials for CKD progression, enrolling 56,413 participants with at least one estimated GFR measurement by 6 months after randomization. We defined acute treatment effects as the mean difference in GFR slope from baseline to 3 months between randomized groups. We performed univariable and multivariable metaregression to assess the effect of intervention type, disease state, baseline GFR, and albuminuria on the magnitude of acute effects. RESULTS The mean acute effect across all studies was -0.21 ml/min per 1.73 m2 (95% confidence interval, -0.63 to 0.22) over 3 months, with substantial heterogeneity across interventions (95% coverage interval across studies, -2.50 to +2.08 ml/min per 1.73 m2). We observed negative average acute effects in renin angiotensin system blockade, BP lowering, and sodium-glucose cotransporter 2 inhibitor trials, and positive acute effects in trials of immunosuppressive agents. Larger negative acute effects were observed in trials with a higher mean baseline GFR. CONCLUSION The magnitude and consistency of acute GFR effects vary across different interventions, and are larger at higher baseline GFR. Understanding the nature and magnitude of acute effects can help inform the optimal design of randomized clinical trials evaluating disease progression in CKD.
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Affiliation(s)
- Brendon L. Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands
| | - Edward F. Vonesh
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Fernando C. Fervenza
- Division of Nephrology and Hypertension and Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - William G. Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Julia B. Lewis
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Philip Kam-Tao Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Bart D. Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | | | - Manuel Praga
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P. Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Jack F.M. Wetzels
- Department of Nephrology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Imperial College London, United Kingdom
| | - Di Xie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Sen T, Li J, Neuen BL, Arnott C, Neal B, Perkovic V, Mahaffey KW, Shaw W, Canovatchel W, Hansen MK, Heerspink HJL. Association Between Circulating GDF-15 and Cardio-Renal Outcomes and Effect of Canagliflozin: Results From the CANVAS Trial. J Am Heart Assoc 2021; 10:e021661. [PMID: 34854308 PMCID: PMC9075362 DOI: 10.1161/jaha.121.021661] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Studies have suggested that sodium glucose co‐transporter 2 inhibitors exert anti‐inflammatory effects. We examined the association of baseline growth differentiation factor‐15 (GDF‐15), a marker of inflammation and cellular injury, with cardiovascular events, hospitalization for heart failure (HF), and kidney outcomes in patients with type 2 diabetes in the CANVAS (Canagliflozin Cardiovascular Assessment Study) and determined the effect of the sodium glucose co‐transporter 2 inhibitor canagliflozin on circulating GDF‐15. Methods and Results The CANVAS trial randomized 4330 people with type 2 diabetes at high cardiovascular risk to canagliflozin or placebo. The association between baseline GDF‐15 and cardiovascular (non‐fatal myocardial infarction, non‐fatal stroke, cardiovascular death), HF, and kidney (40% estimated glomerular filtration rate decline, end‐stage kidney disease, renal death) outcomes was assessed using multivariable adjusted Cox regression models. During median follow‐up of 6.1 years (N=3549 participants with available samples), 555 cardiovascular, 129 HF, and 137 kidney outcomes occurred. Each doubling in baseline GDF‐15 was significantly associated with a higher risk of cardiovascular (hazard ratio [HR], 1.2; 95% CI, 1.0‒1.3), HF (HR, 1.5; 95% CI, 1.2‒2.0) and kidney (HR, 1.5; 95% CI, 1.2‒2.0) outcomes. Baseline GDF‐15 did not modify canagliflozin’s effect on cardiovascular, HF, and kidney outcomes. Canaglifozin treatment modestly lowered GDF‐15 compared with placebo; however, GDF‐15 did not mediate the protective effect of canagliflozin on cardiovascular, HF, or kidney outcomes. Conclusions In patients with type 2 diabetes at high cardiovascular risk, higher GDF‐15 levels were associated with a higher risk of cardiovascular, HF, and kidney outcomes. Canagliflozin modestly lowered GDF‐15, but GDF‐15 reduction did not mediate the protective effect of canagliflozin.
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Affiliation(s)
- Taha Sen
- Department of Clinical Pharmacy and PharmacologyUniversity of GroningenThe Netherlands
| | - Jingwei Li
- The George Institute for Global HealthUNSW SydneySydneyAustralia
| | - Brendon L. Neuen
- The George Institute for Global HealthUNSW SydneySydneyAustralia
| | - Clare Arnott
- The George Institute for Global HealthUNSW SydneySydneyAustralia
| | - Bruce Neal
- The George Institute for Global HealthUNSW SydneySydneyAustralia
| | - Vlado Perkovic
- The George Institute for Global HealthUNSW SydneySydneyAustralia
| | - Kenneth W. Mahaffey
- Department of MedicineStanford Center for Clinical ResearchStanford University School of MedicineStanfordCA
| | - Wayne Shaw
- Janssen Research & Development, LLCRaritanNJ
| | | | | | - Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and PharmacologyUniversity of GroningenThe Netherlands
- The George Institute for Global HealthUNSW SydneySydneyAustralia
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Vijay K, Neuen BL, Lerma EV. When Heart Failure Collides with Diabetes and Chronic Kidney Disease: Challenges and Opportunities. Cardiorenal Med 2021; 12:1-10. [PMID: 34802000 DOI: 10.1159/000520909] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 11/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Heart failure (HF), diabetes mellitus (DM), and chronic kidney disease (CKD) are commonly occurring and interlinked conditions. Approximately 25% to 40% of patients with HF have DM, and approximately 40% to 50% of patients with HF have CKD. Both DM and CKD are associated with increased risk of incident HF. Further, 40% of people with DM develop CKD, making DM the leading cause of kidney failure globally. Importantly, 16% of patients with HF have both comorbid DM and CKD, and the combination of these 3 comorbidities is associated with substantially increased risk for hospitalization and mortality. Mechanisms that underlie the relationships between HF, DM, and CKD are complex but likely relate to shared cardiovascular and metabolic risk factors, as well as downstream effects on inflammation, oxidative stress, and neurohormonal pathways. SUMMARY This review outlines the epidemiology and links between HF, DM, and CKD, as well as current clinical evidence for the treatment of individuals with a combination of these comorbidities. A case study of a patient with concomitant HF, DM, and CKD is discussed to explore potential treatment approaches for patients in whom all 3 comorbidities exist. Key Messages: Treatment plans for patients with a combination of these 3 comorbidities should consider the available clinical evidence.
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Affiliation(s)
- Kris Vijay
- Abrazo Arizona Heart Institute and Hospital, Phoenix, Arizona, USA
| | - Brendon L Neuen
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Edgar V Lerma
- University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
- Advocate Christ Medical Center, Oak Lawn, Illinois, USA
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Young TK, Li JW, Kang A, Heerspink HJL, Hockham C, Arnott C, Neuen BL, Zoungas S, Mahaffey KW, Perkovic V, de Zeeuw D, Fulcher G, Neal B, Jardine M. Effects of canagliflozin compared with placebo on major adverse cardiovascular and kidney events in patient groups with different baseline levels of HbA 1c, disease duration and treatment intensity: results from the CANVAS Program. Diabetologia 2021; 64:2402-2414. [PMID: 34448033 PMCID: PMC8494676 DOI: 10.1007/s00125-021-05524-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/19/2021] [Indexed: 01/14/2023]
Abstract
AIMS/HYPOTHESIS Type 2 diabetes mellitus can manifest over a broad clinical range, although there is no clear consensus on the categorisation of disease complexity. We assessed the effects of canagliflozin, compared with placebo, on cardiovascular and kidney outcomes in the CANagliflozin cardioVascular Assessment Study (CANVAS) Program over a range of type 2 diabetes mellitus complexity, defined separately by baseline intensity of treatment, duration of diabetes and glycaemic control. METHODS We performed a post hoc analysis of the effects of canagliflozin on major adverse cardiovascular events (MACE) according to baseline glucose-lowering treatments (0 or 1, 2 or 3+ non-insulin glucose-lowering treatments, or insulin-based treatment), duration of diabetes (<10, 10 to 16, >16 years) and HbA1c (≤53.0 mmol/mol [<7.0%], >53.0 to 58.5 mmol/mol [>7.0% to 7.5%], >58.5 to 63.9 mmol/mol [>7.5 to 8.0%], >63.9 to 69.4 mmol/mol [8.0% to 8.5%], >69.4 to 74.9 mmol/mol [>8.5 to 9.0%] or >74.9 mmol/mol [>9.0%]). We analysed additional secondary endpoints for cardiovascular and kidney outcomes, including a combined kidney outcome of sustained 40% decline in eGFR, end-stage kidney disease or death due to kidney disease. We used Cox regression analyses and compared the constancy of HRs across subgroups by fitting an interaction term (p value for significance <0.05). RESULTS At study initiation, 5095 (50%) CANVAS Program participants were treated with insulin, 2100 (21%) had an HbA1c > 74.9 mmol/mol (9.0%) and the median duration of diabetes was 12.6 years (interquartile interval 8.0-18 years). Canagliflozin reduced MACE (HR 0.86 [95% CI 0.75, 0.97]) with no evidence that the benefit differed between subgroups defined by the number of glucose-lowering treatments, the duration of diabetes or baseline HbA1c (all p-heterogeneity >0.17). Canagliflozin reduced MACE in participants receiving insulin with no evidence that the benefit differed from other participants in the trial (HR 0.85 [95% CI 0.72, 1.00]). Similar results were observed for other cardiovascular outcomes and for the combined kidney outcome (HR for combined kidney outcome 0.60 [95% CI 0.47, 0.77]), with all p-heterogeneity >0.37. CONCLUSIONS/INTERPRETATION In people with type 2 diabetes mellitus at high cardiovascular risk, there was no evidence that cardiovascular and renal protection with canagliflozin differed across subgroups defined by baseline treatment intensity, duration of diabetes or HbA1c.
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Affiliation(s)
- Tamara K Young
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | - Jing-Wei Li
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | - Amy Kang
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | | | - Carinna Hockham
- The George Institute for Global Health, Imperial College London, London, UK.
| | - Clare Arnott
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia.
- University of Sydney, Sydney, NSW, Australia.
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | - Sophia Zoungas
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
- Monash University, Melbourne, VIC, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Bruce Neal
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | - Meg Jardine
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
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Neuen BL, Oshima M, Perkovic V, Arnott C, Bakris G, Cannon CP, Charytan DM, Jardine M, Levin A, Neal B, Pollock C, Wheeler DC, Mahaffey KW, Heerspink HJL. Effects of canagliflozin on hyperkalaemia and serum potassium in people with diabetes and chronic kidney disease: insights from the CREDENCE trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Hyperkalaemia is a common complication of type 2 diabetes mellitus (T2DM) and limits the optimal use of agents that block the renin-angiotensin aldosterone system (RAAS), particularly in patients with chronic kidney disease (CKD). In patients with CKD, sodium glucose cotransporter 2 (SGLT2) inhibitors provide cardiorenal protection, but whether they affect the risk of hyperkalaemia remains uncertain.
Purpose
We sought to assess the effect of canagliflozin on hyperkalaemia and other potassium-related outcomes in people with T2DM and CKD by conducting a post-hoc analysis of the CREDENCE trial.
Methods
The CREDENCE trial randomized 4401 participants with T2DM and CKD to the SGLT2 inhibitor canagliflozin or matching placebo. In this post-hoc analysis using an intention-to-treat approach, we assessed the effect of canagliflozin on a composite outcome of time to either investigator-reported hyperkalaemia or the initiation of potassium binders. We also analysed effects on central laboratory-determined hyper- and hypokalaemia (serum potassium ≥6.0 and <3.5 mmol/L, respectively) and change in serum potassium.
Results
At baseline the mean serum potassium in canagliflozin and placebo arms was 4.5 mmol/L; 4395 (99.9%) participants were receiving renin angiotensin system blockade. Canagliflozin reduced the risk of investigator-reported hyperkalaemia or initiation of potassium binders (HR 0.78, 95% CI 0.64–0.95, p=0.014; Figure 1). The incidence of laboratory-determined hyperkalaemia was similarly reduced (HR 0.77, 95% CI 0.61–0.98, p=0.031; Figure 2); the risk of hypokalaemia (HR 0.92, 95% CI 0.71–1.20, p=0.53) was not increased. Mean serum potassium over time with canagliflozin was similar to that of placebo.
Conclusion
Among patients treated with RAAS inhibitors, SGLT2 inhibition with canagliflozin may reduce the risk of hyperkalaemia in people with T2DM and CKD without increasing the risk of hypokalaemia.
Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2
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Affiliation(s)
- B L Neuen
- The George Institute for Global Health, Sydney, Australia
| | - M Oshima
- The George Institute for Global Health, Sydney, Australia
| | - V Perkovic
- University of New South Wales Sydney, Sydney, Australia
| | - C Arnott
- The George Institute for Global Health, Sydney, Australia
| | - G Bakris
- University of Chicago Medicine, Chicago, United States of America
| | - C P Cannon
- Harvard Medical School, Boston, United States of America
| | - D M Charytan
- New York University Langone Medical Center, New York, United States of America
| | - M Jardine
- University of Sydney, Sydney, Australia
| | - A Levin
- University of British Columbia, Vancouver, Canada
| | - B Neal
- The George Institute for Global Health, Sydney, Australia
| | - C Pollock
- University of Sydney, Sydney, Australia
| | - D C Wheeler
- University College London, London, United Kingdom
| | - K W Mahaffey
- Stanford University Medical Center, Stanford, United States of America
| | - H J L Heerspink
- University Medical Center Groningen, Groningen, Netherlands (The)
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Sen T, Li J, Neuen BL, Neal B, Arnott C, Parikh CR, Coca SG, Perkovic V, Mahaffey KW, Yavin Y, Rosenthal N, Hansen MK, Heerspink HJL. Effects of the SGLT2 inhibitor canagliflozin on plasma biomarkers TNFR-1, TNFR-2 and KIM-1 in the CANVAS trial. Diabetologia 2021; 64:2147-2158. [PMID: 34415356 PMCID: PMC8423682 DOI: 10.1007/s00125-021-05512-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/19/2021] [Indexed: 01/08/2023]
Abstract
AIMS/HYPOTHESIS Higher plasma concentrations of tumour necrosis factor receptor (TNFR)-1, TNFR-2 and kidney injury molecule-1 (KIM-1) have been found to be associated with higher risk of kidney failure in individuals with type 2 diabetes in previous studies. Whether drugs can reduce these biomarkers is not well established. We measured these biomarkers in samples of the CANVAS study and examined the effect of the sodium-glucose cotransporter 2 inhibitor canagliflozin on these biomarkers and assessed whether the early change in these biomarkers predict cardiovascular and kidney outcomes in individuals with type 2 diabetes in the CANagliflozin cardioVascular Assessment Study (CANVAS). METHODS Biomarkers were measured with immunoassays (proprietary multiplex assay performed by RenalytixAI, New York, NY, USA) at baseline and years 1, 3 and 6. Mixed-effects models for repeated measures assessed the effect of canagliflozin vs placebo on the biomarkers. Associations of baseline levels and the early change (baseline to year 1) for each biomarker with the kidney outcome were assessed using multivariable-adjusted Cox regression. RESULTS In total, 3523/4330 (81.4%) of the CANVAS participants had available samples at baseline. Each doubling in baseline TNFR-1, TNFR-2 and KIM-1 was associated with a higher risk of kidney outcomes, with corresponding HRs of 3.7 (95% CI 2.3, 6.1; p < 0.01), 2.7 (95% CI 2.0, 3.6; p < 0.01) and 1.5 (95% CI 1.2, 1.8; p < 0.01), respectively. Canagliflozin reduced the level of the plasma biomarkers with differences in TNFR-1, TNFR-2 and KIM-1 between canagliflozin and placebo during follow-up of 2.8% (95% CI 3.4%, 1.3%; p < 0.01), 1.9% (95% CI 3.5%, 0.2%; p = 0.03) and 26.7% (95% CI 30.7%, 22.7%; p < 0.01), respectively. Within the canagliflozin treatment group, each 10% reduction in TNFR-1 and TNFR-2 at year 1 was associated with a lower risk of the kidney outcome (HR 0.8 [95% CI 0.7, 1.0; p = 0.02] and 0.9 [95% CI 0.9, 1.0; p < 0.01] respectively), independent of other patient characteristics. The baseline and 1 year change in biomarkers did not associate with cardiovascular or heart failure outcomes. CONCLUSIONS/INTERPRETATION Canagliflozin decreased KIM-1 and modestly reduced TNFR-1 and TNFR-2 compared with placebo in individuals with type 2 diabetes in CANVAS. Early decreases in TNFR-1 and TNFR-2 during canagliflozin treatment were independently associated with a lower risk of kidney disease progression, suggesting that TNFR-1 and TNFR-2 have the potential to be pharmacodynamic markers of response to canagliflozin.
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Affiliation(s)
- Taha Sen
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Jingwei Li
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Brendon L Neuen
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Clare Arnott
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Steven G Coca
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Yshai Yavin
- Janssen Research & Development LLC, Spring House, PA, USA
| | | | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands.
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia.
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Neuen BL, Weldegiorgis M, Herrington WG, Ohkuma T, Smith M, Woodward M. Changes in GFR and Albuminuria in Routine Clinical Practice and the Risk of Kidney Disease Progression. Am J Kidney Dis 2021; 78:350-360.e1. [PMID: 33895181 DOI: 10.1053/j.ajkd.2021.02.335] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 02/14/2021] [Indexed: 12/16/2022]
Abstract
RATIONALE & OBJECTIVE Changes in urinary albumin-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) have been used separately as alternative kidney disease outcomes in randomized trials. We tested the hypothesis that combined changes in UACR and eGFR predict advanced kidney disease better than either alone. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 91,319 primary care patients assembled from the Clinical Practice Research Datalink in the United Kingdom between 2000 and 2015. EXPOSURES Changes in UACR and eGFR (categorized as ≥30% increase, stable, or ≥30% decrease), alone and in combination, over a 3-year period. OUTCOMES The primary outcome was advanced CKD (sustained eGFR <30 mL/min/1.73 m2); secondary outcomes included kidney failure, cardiovascular disease, and all-cause mortality. ANALYTICAL APPROACH Multivariable Cox regression with bias from missing values assessed using multiple imputation; discrimination statistics compared across exposure groups. RESULTS 91,319 individuals were studied, with a mean eGFR of 72.6 mL/min/1.73 m2 and median UACR of 9.7 mg/g; 70,957 (77.7%) had diabetes. During a median follow-up of 2.9 years, 2,541 people progressed to advanced CKD. Compared with stable values, hazard ratios for a ≥30% increase in UACR and ≥30% decrease in eGFR were 1.78 (95% CI, 1.59-1.98) and 7.53 (95% CI, 6.70-8.45), respectively, for the outcome of advanced CKD. Compared with stable values of both, the hazard ratio for the combination of an increase in UACR and a decrease in eGFR was 15.15 (95% CI, 12.43-18.46) for the outcome of advanced CKD. The combination of changes in UACR and eGFR predicted kidney outcomes better than either alone. LIMITATIONS Selection bias, relatively small proportion of individuals without diabetes, and very few kidney failure events. CONCLUSIONS In a large-scale general population, the combination of an increase in UACR and a decrease in eGFR was strongly associated with the risk of advanced CKD. Further assessment of combined changes in UACR and eGFR as an alternative outcome for kidney failure in trials of CKD progression is warranted.
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Affiliation(s)
- Brendon L Neuen
- George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia.
| | - Misghina Weldegiorgis
- George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia; Department of Epidemiology and Biostatistics, School of Public Health, The George Institute for Global Health, Imperial College London, London
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, United Kingdom
| | - Toshiaki Ohkuma
- George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia; Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Margaret Smith
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Mark Woodward
- George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia; Department of Epidemiology and Biostatistics, School of Public Health, The George Institute for Global Health, Imperial College London, London; Department of Epidemiology, John Hopkins University, Baltimore, MD
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Abstract
Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA.
| | - Tazeen H Jafar
- Duke-NUS Graduate Medical School, Singapore; Department of Renal Medicine, Singapore General Hospital, Singapore; Duke Global Health Institute, Durham, NC, USA
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; United Kingdom Renal Registry, Bristol, UK; Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales Sydney, Sydney, NSW, Australia
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