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.

Role of post-acute myocardial infarction clinic in secondary prevention

Funding Acknowledgements

Type of funding sources: None.

Background

There is a 5% increased risk of death from cardiovascular causes following acute myocardial infarction[1]. One of the critical factors to improve long-term prognosis is evidence-based medication, but the limiting factors are adherence and optimal up-titration. Studies have shown one of the ways to improve this is early follow up[2]. Post-acute myocardial infarction(AMI) clinics help bridge this gap[3].

Purpose

We realised that the follow-up time for our patients was 257 days. So we created a dedicated post-AMI clinic. We wanted to reduce wait times, improve patient compliance, optimise medication, and manage risk factors.

Methods

We collected retrospective data from our post-AMI clinic between august to december 2020 for 52 patients who had a myocardial infarction.

Results

In 52 patients seen, post-AMI clinic reduced follow up time from 257 to 65 days. In the post-AMI clinic, we picked up the new diagnosis of diabetes in 5.8% of patients. Most medicines required optimisation as depicted in Table 1 and Histogram 1.

Conclusions

Overall, Significant number of patients in post-AMI clinic had early follow up, secondary prevention optimisation. This project demonstrates how Post-AMI clinics are important part of secondary prevention. They should be part of routine post-AMI care in all hospitals.

Table 1 Age 20-40 40-60 60-80 80-100 2 20 24 6 Lesion LAD Cx RCA &gt;1 lesion 23 4 16 9 Meds Optsd B-Blocker ACE-i/ARB Statins DAPt 5(10.8%) 29(55.8%) 8(15.4%) 1(1.9%) Referred to Diabetes Heart failure Need ongoing review 5 2 5 Meds = Medication, Optsd= Optimised, B-Blocker = Beta blocker, ACE-i = Angiotensin converting enzyme inhibitors. ARB= Angiotensin receptor blockers, DAPT = Dual anti-platelet therapy

Abstract Figure. Histogram 1

Spectral characteristics of urine from patients with end-stage kidney disease analyzed using Raman Chemometric Urinalysis (Rametrix)

Raman Chemometric Urinalysis (Rametrix^TM) was used to discern differences in Raman spectra from (i) 362 urine specimens from patients receiving peritoneal dialysis (PD) therapy for end-stage kidney disease (ESKD), (ii) 395 spent dialysate specimens from those PD therapies, and (iii) 235 urine specimens from healthy human volunteers. Rametrix^TM analysis includes spectral processing (e.g., truncation, baselining, and vector normalization); principal component analysis (PCA); statistical analyses (ANOVA and pairwise comparisons); discriminant analysis of principal components (DAPC); and testing DAPC models using a leave-one-out build/test validation procedure. Results showed distinct and statistically significant differences between the three types of specimens mentioned above. Further, when introducing “unknown” specimens, Rametrix^TM was able to identify the type of specimen (as PD patient urine or spent dialysate) with better than 98% accuracy, sensitivity, and specificity. Rametrix^TM was able to identify “unknown” urine specimens as from PD patients or healthy human volunteers with better than 96% accuracy (with better than 97% sensitivity and 94% specificity). This demonstrates that an entire Raman spectrum of a urine or spent dialysate specimen can be used to determine its identity or the presence of ESKD by the donor.

Spectral characteristics of urine specimens from healthy human volunteers analyzed using Raman chemometric urinalysis (Rametrix)

Raman chemometric urinalysis (Rametrix^™) was used to analyze 235 urine specimens from healthy individuals. The purpose of this study was to establish the “range of normal” for Raman spectra of urine specimens from healthy individuals. Ultimately, spectra falling outside of this range will be correlated with kidney and urinary tract disease. Rametrix^™ analysis includes direct comparisons of Raman spectra but also principal component analysis (PCA), discriminant analysis of principal components (DAPC) models, multivariate statistics, and it is available through GitHub as the Rametrix^™ LITE Toolbox for MATLAB^®. Results showed consistently overlapping Raman spectra of urine specimens with significantly larger variances in Raman shifts, found by PCA, corresponding to urea, creatinine, and glucose concentrations. A 2-way ANOVA test found that age of the urine specimen donor was statistically significant (p < 0.001) and donor sex (female or male identification) was less so (p = 0.0526). With DAPC models and blind leave-one-out build/test routines using the Rametrix^™ PRO Toolbox (also available through GitHub), an accuracy of 71% (sensitivity = 72%; specificity = 70%) was obtained when predicting whether a urine specimen from a healthy unknown individual was from a female or male donor. Finally, from female and male donors (n = 4) who contributed first morning void urine specimens each day for 30 days, the co-occurrence of menstruation was found statistically insignificant to Rametrix^™ results (p = 0.695). In addition, Rametrix^™ PRO was able to link urine specimens with the individual donor with an average of 78% accuracy. Taken together, this study established the range of Raman spectra that could be expected when obtaining urine specimens from healthy individuals and analyzed by Rametrix^™ and provides the methodology for linking results with donor characteristics.

A Multi-Center, Randomized, Controlled, Pivotal Study to Assess the Safety and Efficacy of a Selective Cytopheretic Device in Patients with Acute Kidney Injury

OBJECTIVE

Acute kidney injury (AKI) is a highly morbid condition in critically ill patients that is associated with high mortality. Previous clinical studies have demonstrated the safety and efficacy of the Selective Cytopheretic Device (SCD) in the treatment of AKI requiring continuous renal replacement therapy in the intensive care unit (ICU).

DESIGN, SETTING, PATIENTS

A randomized, controlled trial of 134 ICU patients with AKI, 69 received continuous renal replacement therapy (CRRT) alone and 65 received SCD therapy.

RESULTS

No significant difference in 60-day mortality was observed between the treated (27/69; 39%) and control patients (21/59; 36%, with six patients lost to follow up) in the intention to treat (ITT) analysis. Of the 19 SCD subjects (CRRT+SCD) and 31 control subjects (CRRT alone) who maintained a post-filter ionized calcium (iCa) level in the protocol's recommended range (≤ 0.4 mmol/L) for greater or equal to 90% of the therapy time, 60-day mortality was 16% (3/19) in the SCD group compared to 41% (11/27) in the CRRT alone group (p = 0.11). Dialysis dependency showed a borderline statistically significant difference between the SCD treated versus control CRRT alone patients maintained for ≥ 90% of the treatment in the protocol's recommended (r) iCa target range of ≤ 0.4 mmol/L with values of, 0% (0/16) and 25% (4/16), respectively (P = 0.10). When the riCa treated and control subgroups were compared for a composite index of 60 day mortality and dialysis dependency, the percentage of SCD treated subjects was 16% versus 58% in the control subjects (p<0.01). The incidence of serious adverse events did not differ between the treated (45/69; 65%) and control groups (40/65; 63%; p = 0·86).

CONCLUSION

SCD therapy may improve mortality and reduce dialysis dependency in a tightly controlled regional hypocalcaemic environment in the perfusion circuit.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01400893 http://clinicaltrials.gov/ct2/show/NCT01400893.

Value of C-reactive protein measurements in exacerbations of chronic obstructive pulmonary disease

C-reactive protein (CRP) has been shown to be a useful and sensitive indicator of pyogenic infections in many clinical situations, including acute pneumonia and infective pulmonary exacerbations in cystic fibrosis patients. Exacerbations of COPD are often, but not always, associated with demonstrable infection. The value of CRP measurement in this situation has not been assessed. We have evaluated CRP measurement in 50 patients [age 71 +/- 8 (SD) years] who were admitted to hospital with clinical evidence of exacerbation [PaO2 = 7.3 +/- 1.3 (SD) kPa, baseline FEV1 = 0.8 +/- 0.4 (SD) l]. These patients all had serial measurement of CRP [polarizing immunofluorescence (Abbot, TDx)], peripheral white cell count (WCC), body temperature, peak expiratory flow rate, Karnofsky performance status and chest X-ray, in addition to serial sputum bacteriological analysis carried out in a specialized laboratory. CRP was elevated (> 10 mg l-1) in all patients (n = 29) with proven infection [103 +/- 98 (SD) mg l-1]. Levels were markedly elevated in patients infected with Streptococcus pneumoniae (mean 156 mg l-1); there was also a rapid fall in the CRP with therapy. WCC fell with therapy, giving a correlation with CRP level (r = 0.44, P < 0.01). Since CRP elevation was observed in patients having exacerbation with proven infections and also in those where infection was not proven, it is possible that, while it is a marker for COPD exacerbation, it is not necessarily a marker of bacterial infection per se. However, it is evident from our study that it is of value in the assessment of exacerbations of COPD, where routine bacterial culture of sputum is often unreliable, and thus the measurement of serum CRP may provide an additional objective indicator of infection.

A comparative analysis of pharmacokinetics of ceftriaxone in serum and pleural fluid in humans: a study of once daily administration by intramuscular and intravenous routes

Pleural fluid and serum pharmacokinetics of ceftriaxone were performed in thirteen patients with pleural effusion. One gram of ceftriaxone was administered once daily intravenously in six patients and intramuscularly in seven patients. Ceftriaxone concentrations were measured in serum and pleural fluids in both groups on the first day of administration and in four patients of the intramuscular group on the fourth day of administration. The mean serum peak concentration at 1 h was 199 mg/L (S.E.M. 63.2) in the iv group and 80.5 mg/L (S.E.M. 12.0) in the im group. The mean serum trough concentrations in the two groups at 24 h were 27.5 mg/L (S.E.M. 12.6) and 29.7 mg/L (S.E.M. 5.2) respectively. In the pleural fluid, mean peak concentration was 20.1 mg/L (S.E.M. 4.7) at 6 h in the iv group and 15.3 mg/L (S.E.M. 5.1) at 12 h in the im group. The mean trough concentration was 9.6 mg/L (S.E.M. 1.9) and 13.3 mg/L (S.E.M. 3.1) at 24 h in the two groups respectively. On the fourth day of intramuscular administration the serum and pleural fluid peak and trough concentrations were higher when compared with the first day, consistent with a cumulative effect. The serum and pleural fluid concentrations of ceftriaxone following intravenous and intramuscular administration were well above the MIC90 of most common respiratory pathogens indicating good penetration into extracellular spaces. Further, these serum and pleural fluid antibiotic concentrations could be maintained even after a single intramuscular injection of the drug, thus indicating its usefulness as a parenteral mode of therapy on a domicilliary basis with a significant cost-saving potential. In conclusion, intramuscular administration of ceftriaxone would appear to be a convenient method of administering parenteral therapy in lower respiratory tract infections in the hospital and community, with pharmacokinetics very similar to those exhibited by the intravenous route.

Adenocarcinoma of the lung--clinical features and survival

Four thousand patients were registered by the Edinburgh Lung Cancer Group in 1981-1987; 9.5% had adenocarcinoma. Of these, 102 patients with pathological confirmation of the diagnosis, presenting to one hospital group in Edinburgh, were reviewed. Two cases were excluded after case note review. Of the remaining 100, 64 were male and 36 were female, with a mean age of 73 years. The majority (89%) were smokers or ex-smokers, and 52% had a poor performance status (Karnofsky Index 10-70). Significantly, more adenocarcinoma patients underwent surgery compared to other cell types (39 vs. 19%, P < 0.01), and less were treated with radiotherapy (19 vs. 31%). The 5-yr survival rate for the adenocarcinoma patients was 19 vs. 7% in the remainder of patients. Of 39 patients referred for surgery, 37 had lung resections and their 5-yr survival rate was 42%. Post-operative staging showed 48% in Stage I, 27% in Stage II and 24% in Stage III. The majority of the long-term survivors had Stage I disease (64%). Forty-two percent of the patients received palliative therapy alone (all died within 10 months). Ten percent of patients receiving radiotherapy survived for 5 yr. Review of these cases suggested two patterns of presentations: (1) patients with poor performance status, extensive disease and often pleural involvement (16%); and (2) patients with more localized disease (39%), many of whom were suitable for surgical resection with surprisingly good prognosis.

Pleural effusion: a clinical review

Pleural effusion is a problem commonly encountered by chest physicians, accounting for approximately 4% of all attendances to the chest clinic. In spite of extensive investigations, a significant proportion (approximately 20%) of effusions defy a diagnostic label. This article discusses the role of established, and some of the newer, techniques which are now available for investigating pleural disease in a clinical setting. The initial approach towards a diagnosis usually begins by distinguishing between transudates and exudates, based on protein and lactate dehydrogenase (LDH) concentrations in fluid (usually in relation to their concentration in serum). The exact role of amylase and LDH (and their isoenzymes) may provide additional information towards a differential diagnosis of various exudative pleural effusions. With newer cytochemical staining techniques on pleural fluid, the diagnostic yield of malignant pleural effusions may be increased by up to 80%. Ultrasound (US) and computed tomographic (CT) scan of the chest have further enhanced the diagnostic yield of undiagnosed pleural effusions, especially in relation to the US or CT guided needle biopsy. The re-emergence of thoracoscopy as the latest diagnostic and therapeutic (e.g. pleurodesis) tool for undiagnosed or recurrent pleural effusions, may help in narrowing the diagnostic dilemma faced by clinicians.