Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Preprocedure COVID-19 Testing in Early Phase of Pandemic

The COVID-19 pandemic led to a nationwide shutdown of elective medical procedures. Upon resumption of services, preprocedure nasopharyngeal swab testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was introduced for all patients requiring surgical or other aerosol-generating procedures. We investigated preprocedure COVID-19 testing in one of the largest U.S. health systems. Patients included in this retrospective, observational study were asymptomatic and scheduled for a procedure or surgery. All patients underwent a nasopharyngeal swab test for SARS-CoV-2 performed 24-72 hours prior to a planned procedure. Clinical demographics, type of procedure, test results, and subsequent procedure status were evaluated. Of 38,608 total patients, there were 277 COVID-19-positive patients (positivity rate: 0.72%). Of those 277, 244 (88%) had procedural delays or cancellations. Of the COVID-19-negative patients, 50 (0.13%) required later hospitalization for COVID-19. Median time from preprocedure negative test to admission was 46.3 ± 27.2 days. In the largest series published on preprocedure COVID-19 testing in the early phase of the pandemic, preprocedure COVID-19 positivity was low. Preprocedure COVID-19 testing had a significant impact on clinical management. Rate of COVID-19 cases requiring hospitalization in the months following the procedure was negligible, suggesting health system policies adequately protected patient safety.

Pancreas graft thrombosis: is there a role for trypsin

PURPOSE

Thrombosis of the pancreas graft is the main cause of early graft loss in pancreas transplantation. We investigated whether hypercoagulability develops locally in the pancreas and contributes to thrombosis formation because of ischemia or reperfusion injury. It was further hypothesized that this might be induced by excessive intravascular trypsin activity.

METHODS

Ten Patients undergoing pancreas transplantation were studied. In addition to the standard operation a 14 French catheter was inserted in the distal part of the splenic vein of the pancreas graft. After reperfusion blood samples were drawn simultaneously from the splenic vein of the pancreas graft (local samples) and the radial artery (systemic samples) at 0,1,2,5,10,30, and 60 minutes after reperfusion.

RESULTS

After reperfusion a progressive hypercoagulability developed locally in the pancreas as seen by an increase of thrombin-antithrombin complexes and only a transient increase of plasmin-antiplasmin complexes. In addition antithrombin 3 and protein c decreased systemically. The alterations seem not to be triggered by trypsin because trypsin activity locally remained low despite trypsinogen release and activation as assessed by trypsinogen activation peptides.

CONCLUSION

Local hypercoagulability might contribute to the development of graft thrombosis, however, the mechanism seems not to be related to ectopic trypsin activation.

Three-dimensional guidance system for implant insertion: Part II. Dual axes table--problem solving

The three-dimensional guidance system for implant insertion is a technique for placing a radiopaque vertical orientation pin over the crest of the alveolar ridge on the stone cast during fabrication of the radiographic guide. The cross-sectional and panoramic reformatted images were reproduced on a Polaroid or 35-mm print. The true vertical orientation pin facilitates (1) identification and the exact planned location of each implant in the reformatted images of the CT scan, (2) establishment of the internal starting point for the osteotomy on a photographic print, (3) optimum implant orientation, and (4) measurement of the angulation between the true vertical orientation line and optimum implant orientation. With the aid of a newly developed dual-axes base and transfer of the internal starting point of each implant to the stone cast, the buccolingual and mesiodistal implant inclinations for each implant were transferred to a surgical guide in the form of surgical steel drill guide tubes. The resulting pilot osteotomy transfers to the alveolar bone the exact starting point and the buccolingual and mesiodistal inclination for each implant. The technique provides a three-dimensional guidance system for implant insertion that is extremely accurate and yet practical.

RLR1 (THO2), required for expressing lacZ fusions in yeast, is conserved from yeast to humans and is a suppressor of SIN4

We isolated a mutation (rlr1-1; required for lacZ RNA) in the Saccharomyces cerevisiae (Sc) RLR1 gene as a suppressor of sin4, a component of the Mediator subcomplex of the RNA polymerase II holoenzyme and a determinant of chromatin structure. RLR1 encodes a deduced protein found also in fission yeast, nematode worms, and humans. The presence of these orthologs suggests that Rlr1 family members comprise a class of putative KEKE motif-containing proteins, characteristic of certain chaperones as well as regulators and subunits of the mammalian 20S proteasome. A role for RLR1 (THO2) in transcription appears to occur at a step subsequent to transcription initiation (see also Piruat, J.I. and Aguilera, A., 1998. EMBO J. 17, 4859-4872); Sc genes fused to the reporter gene lacZ were expressed at a very low level, while the corresponding native chromosomal genes were expressed at approximately normal levels in rlr1 mutants. Our studies show that rlr1 mutations cause a wide range of growth defects in addition to their novel affect on lacZ.

Three-dimensional guidance system for implant insertion: Part I

A technique is presented, with two sets of newly designed drills, that facilitates three-dimensional guided insertion of implants. A radiographic guide has been fabricated with titanium markers that are transferred into the CT scan reformatted images. The resulting cross-sectional and panoramic reformatted images provide the precise location for each implant. The buccolingual and mesiodistal inclinations of each implant are measured and transferred to a surgical guide that contains steel drill guide tubes. The starting point and three-dimensional orientation of each implant is then transferred to a pilot osteotomy. The widening of an osteotomy, with end-cutting drills of the usual design, can lead to the loss of orientation because a wider drill cannot be effectively guided by a smaller diameter osteotomy. A newly designed set of drills has been developed that maintains tracking of the original orientation as the incremental increase in width proceeds. The three-dimensional guidance system for implant insertion was first accomplished in vitro and then on patients.

An evaluation of torque (moment) on implant/prosthesis with staggered buccal and lingual offset

The supposition that staggered buccal and lingual implant offset is biomechanically advantageous was examined mathematically. The method of evaluation utilized a standard hypothetical geometric configuration from which implants could be staggered buccally and/or lingually in both arches. Torque (moment) values were calculated at the gold screw, abutment screw, and 3.5 mm apical to the head of the implant. Comparisons were made in percentages of change from the hypothetical standard to the buccal and/or lingual implant offset. In the maxillary arch, buccal offset decreased the torque (moment) while lingual offset increased it. If more lingually offset implants were present in the maxillary restoration, the total torque would be greater than if they were all in a straight line. Staggered buccolingual implant alignment often requires abutment reangulation. The resultant line of force produced by occlusal anatomy usually results in buccal inclination in the maxillary arch and lingual inclination in the mandibular arch. As a result, mandibular implant/prostheses are greatly favored over similar maxillary configurations because the mandibular resultant line of force usually passes lingually, closer to the components and supporting bone and considerably less torque is produced. Therefore, the concept of staggered offset for multiple implant-supported prostheses can be utilized on the mandible but is not recommended for the maxilla where maximum uniform buccal implant orientation is advised.

A comparison of implant/prosthesis loading with four clinical variables

A comparative evaluation of torque at the gold screw, abutment screw, and implant was calculated for cuspal inclination, implant inclination, and horizontal and vertical implant offset. The method of comparison was expressed as a percentage of change from a hypothetical standard maxillary implant/prosthesis configuration. These data facilitate rational clinical conclusions that cuspal inclination produces the most torque, followed by maxillary horizontal implant offset, while implant inclination and apical implant offset produce minimal torque. Although these data are not intended as a quantitative analysis, they nonetheless provide a practical guide to diagnosis and treatment planning.

Biomechanical considerations when combining tooth-supported and implant-supported prostheses

The force distribution of multiple tooth-supported and implant-supported prostheses is completely different. A direct correlation exists between the degree of flexion at the site of loading and the amount of force distribution to other members of the prosthesis. Micromovement produced by the periodontal fibers facilitates force distribution to all the root surfaces of the natural tooth abutments. The rigidity of the implant/abutment/prosthesis configuration concentrates the force at the crestal bone at the site of loading with limited distribution to the remaining implants. Differential mobility concentrates the force distribution to the bone support of the most rigid members of splinted natural teeth or to the implants when they are united with natural teeth in a combined prosthesis. Implants always support the natural teeth and never the other way around. Therefore a nonrigid attachment is recommended between a tooth-supported prosthesis and an implant-supported prosthesis when they are combined. However, when implants are interspersed with natural teeth in the same prosthesis, the restoration will be implant borne. This requires special force distribution analysis to prevent implant overload.

TSF3, a global regulatory protein that silences transcription of yeast GAL genes, also mediates repression by alpha 2 repressor and is identical to SIN4

TSF3 encodes one of six (TSF1 to TSF6) recently identified global negative regulators of transcription in Saccharomyces cerevisiae. Mutant tsf3 strains exhibit defects in transcriptional silencing of the GAL1 promoter, allow expression from upstream activation sequence-less promoters, and exhibit pleiotropic defects in cell growth and development. Here we show that TSF3 is involved in transcriptional silencing mediated by the alpha 2 repressor and demonstrate that specific systems of transcriptional silencing may depend on the more global role of TSF3. Cloning and sequencing of TSF3 allowed us to predict a 974-amino-acid gene product identical to SIN4, a negative regulator of transcription of the HO (homothallism) mating type switching endonuclease. TSF3 disruptions are not lethal but result in phenotypes similar to those of the originally isolated alleles. Our results, together with those of Y. W. Jiang and D. J. Stillman (Mol. Cell. Biol. 12:4503-4514, 1992), suggest that TSF3 (SIN4) affects the function of the basal transcription apparatus, and this effect in turn alters the manner in which the latter responds to upstream regulatory proteins.

An update on the external ear resonance in infants and young children

The diffuse field to ear canal sound pressure transformations determined for 26 children (34 ears) from birth to 3 years old, confirm the earlier findings [Kruger B. Ruben RJ. Acta Otolaryngol (Stockh) 1987; 103:578-85] that the external ear fundamental resonance frequency is significantly higher at birth (about 6 kHz), and decreases with age to adult values (2.7 kHz) by the second year. The transformations were measured with either single or double probe tubes (coupled to miniature microphones) that were placed in the ear canal of sleeping infants. The accuracy of the magnitude of the transformations is discussed. Previously reported implications for hearing aid selection are supported.

The acoustic properties of the infant ear. A preliminary report

This is a preliminary report about the acoustic characteristics of the external ears of infants. A technique was developed to insert a probe tube that is attached to a miniature microphone into the external auditory canals of sleeping infants. The inlet to the microphone was positioned in the lateral half of the external auditory canal. A diffuse sound field (spectral density of approximately 45 dB SPL) was introduced. The microphone output was recorded, and its Fourier Transform was computed. Diffuse-field-to-ear canal sound pressure level transformations were determined for infants ranging in age from newborn to 37 months. Representative sound pressure level transformations are presented. These are shown to vary systematically with the age of the child. The resonance frequency of the external ear is high in the newborns and declines with age. The asymptotic value (approximately 2,700 Hz) is reached during the second year of life. These findings have potential implications for fitting hearing aids on infants and children.

Accuracy of the Welch Allyn AudioScope and traditional hearing screening for children with known hearing loss

The Welch Allyn AudioScope is a new screening instrument that allows both audiometric testing at 500, 1000, 2000, and 4000 Hz at 25 dB hearing level and otoscopic examination. Sixty-eight patients between 3 and 9 years of age with normal hearing or a variety of hearing losses comprised the study population. Immediately after receiving an audiologic evaluation the subjects were screened with a traditional screening audiometer and two examinations with the AudioScope, performed in a clinic examining room by pediatricians and nurse practitioners unaware of the children's hearing status. The AudioScope was as accurate as traditional hearing screening in identifying children with normal hearing and those with hearing loss. Log-linear modeling demonstrated that the results of AudioScope testing were similar to those of traditional hearing screening. However, the false positive rate was higher at 500 Hz for the first AudioScope examination, suggesting the need for two AudioScope tests. The AudioScope was quick and easy to use, nonthreatening to the subjects, less expensive than a pure-tone screening audiometer, and does not require a sound-treated room.

Selective auditory attention abilities of learning disabled and normal achieving children

This study investigated the selective auditory attention skills of learning disabled children as compared with the performance of normal achievers aged 7 through 9 years. The task consisted of pointing to the appropriate picture of a monosyllabic word presented diotically. The task was always presented first in quiet and then under three noise (distractor) conditions: white noise (nonlinguistic), speech backwards (linguistic nonsemantic), and speech forward (semantic). The performance of the LD children was affected more than the performance of normal achievers under all distractor conditions, with the greatest difference found when the distractor was semantic. The performance of 8-year-olds was significantly better than 7-year-olds on these listening tasks. These findings suggest that LD children may be differentiated from normal achievers using a selective auditory attention task with a semantic distractor.

Middle ear transmission losses caused by tympanic membrane perforations in cats

Losses (determined by measuring microphonic responses) were essentially identical, regardless of whether produced by admittance of sound into the middle ear via perforations in the tympanic membrane (TM) or in the bulla. With SPLs monitored directly at the TM, losses increased at 12 dB/oct with inverse frequency for f less than 1 kHz, a pattern determined by the changes in the (calculated) net sound pressure acting from front and back on the TM. Clinically, hearing losses due to TM perforations are frequency-independent. The difference between the two situations has mainly to do with the use of precalibrated SPLs in Clinical Audiometry.