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.

Health literacy levels and its determinants among people with asthma in Malaysian primary healthcare settings: a cross-sectional study

BACKGROUND

Limited health literacy among people with asthma is associated with poor adherence to self-management activities, thus poor clinical outcomes. This study aimed to determine the prevalence of health literacy level and its determinants among people with asthma in the Malaysian primary healthcare settings.

METHOD

A cross-sectional study was conducted among participants aged > 18 years with asthma who attended five primary health clinics in Malaysia. Systematic random sampling was employed with a final sample of 550 participants. The questionnaires included the validated Malay version of Health Literacy Scale (HLS) and asthma control questionnaire (ACQ). Statistical analysis was done using SPSS version 25. Multiple logistic regression was performed to determine the determinants for limited health literacy.

RESULTS

The participants mean age of the participants was 48 (SD15.4) years. Most of the participants were women (64%) and of Malay ethnicity (51.1%). Nearly half had a secondary level of education, n = 112, (45.8%). Mean duration of asthma diagnosis is 20.6 (SD 15.9) years. More than half (62.5%) had a family history of asthma. About half (50.9%) had uncontrolled asthma, with 87.3% self-rated themselves as having controlled asthma. About a third (29.1%) received education on of asthma action plan, but only 7.1% of these owned a written version an asthma action plan. Limited health literacy accounts for 60.5% of the participants. The significant determinants for limited health literacy included lower educational attainment (p < 0.001), family history of asthma (p = 0.034), < 20 years duration of asthma diagnosis (p = 0.031) and not receiving asthma action plan education (p < 0.001).

CONCLUSION

In this study population, more than half of the people living with asthma were found to have limited health literacy, which was associated with not having received self-management education supported by an asthma action plan. Future interventions should include strategies that ensure they meet the needs of people with limited health literacy.

Salt creeping as a self-amplifying crystallization process

Salt creeping is a ubiquitous phenomenon in which crystals precipitate far from an evaporating salt solution boundary, which constitutes a major problem in outdoor electronics, civil engineering, artworks, and agriculture. We report a novel experimental approach that allows to quantitatively describe the creeping mechanism and demonstrate its universality with respect to different salts. We show that there exists a critical contact angle below which salt creeping occurs, provided also the nucleation of multiple crystals is favored. The precipitation of new crystals happens ahead of the contact line by the meniscus that progressively advances over the crystals forming also nanometric precursor films. This enlarges the evaporative area, causing an exponential increase in the crystal mass in time. The self-amplifying process then results in a spectacular three-dimensional crystal network at macroscopic distances from the solution reservoir. These findings also allow us to control the creeping by using crystallization modifiers.

P722Glycemic control with canagliflozin, a SGLT-2 inhibitor, attenuates atherosclerosis and endothelial dysfunction in diabetic apolipoprotein e-deficient mice

Background

Canagliflozin is a SGLT-2 inhibitor, a novel type of drug for type 2 diabetes mellitus treatment. Recent studies have shown that SGLT-2 inhibitors reduce cardiovascular events, although the mechanism is still unknown.

Purpose

The aim of our study was to examine the effect of canagliflozin on vascular endothelial cell.

Method

Eight-week-old apolipoprotein E-deficient (ApoE−/−) mice were treated with streptozotocin (STZ, 75 mg/kg/day) in three consecutive days by intraperitoneal injection to induce diabetes. Diabetic ApoE−/− mice were treated with canagliflozin (30 mg/kg/day) by gavage for 12 weeks or 8 weeks to examine its effect on atherosclerosis or endothelial function, respectively.

Results

Canagliflozin significantly decreased blood glucose level (P<0.001), triglyceride level (P<0.05), and total cholesterol level (P<0.05). Sudan IV staining on the aortic arch showed that canagliflozin decreased atherosclerotic lesion progression (P<0.05). Histological analyses using atherosclerotic lesions in the aortic root showed that canagliflozin reduced lipid disposition (P<0.01), macrophage accumulation (P<0.001, and expression of adhesion molecules such as ICAM-1, and VCAM-1 (P<0.01, and P<0.05 respectively). Canagliflozin also attenuated the development of endothelial dysfunction as determined by acetylcholine-dependent vasodilation (P<0.05), and reduced the expression of inflammatory molecules, such as ICAM-1 and VCAM-1 (P<0.01), also MCP-1, F4/80, IL6, and iNOS (P<0.05) in the aorta. Canagliflozin reduced oxidative stress as determined by the reduction of the expression of NOX2, NOX4, p22phox, p47phox in the aorta and by the urinary excretion of 8-OHdG. In in vitro experiment using human umbilical vein endothelial cells (HUVEC), methylglyoxal (MGO), a precursor of advanced glycation end products, significantly increased the expression of inflammatory molecules such as ICAM-1, MCP-1, and p22phox in (P<0.05, respectively). MGO also decreased the phosphorylation of eNOSser1177 and Akt, and increased phosphorylation of P38 MAPK in HUVEC.

Conclusion

Glucose lowering effect by canagliflozin attenuates the development of endothelial dysfunction and atherogenesis in diabetic ApoE−/− mice. Anti-inflammatory effect due to the reduction of glucose toxicity on endothelial cells might be one of the mechanisms.

Influence of feeding increasing levels of dry or modified wet corn distillers grains plus solubles in whole corn grain-based finishing cattle diets on pancreatic α-amylase and trypsin activity

The objectives of this study were to determine the effect of dietary inclusion [0%–50% of diet dry matter (DM)] and form (dry and modified wet) of corn distillers grains plus solubles (DGS) on pancreatic α-amylase and trypsin activities in calves. Feeding up to 50% DGS did not negatively impact pancreatic exocrine function.

Influence of feeding increasing levels of dry or modified wet corn distillers’ grains plus solubles in whole corn grain-based finishing diets on hepatic and renal mass, and glutathione peroxidase and urea cycle enzyme activities in finishing cattle

Salim, H., Wood, K. M., Cant, J. P. and Swanson, K. C. 2015. Influence of feeding increasing levels of dry or modified wet corn distillers’ grains plus solubles in whole corn grain-based finishing diets on hepatic and renal mass, and glutathione peroxidase and urea cycle enzyme activities in finishing cattle. Can. J. Anim. Sci. 95: 407–415. Forty-two cross-bred steers (BW=357±5.8 kg) fed whole corn grain-based finishing diets were used in a completely randomized block (60, 120, or 180 d on feed) design (2×3 factorial arrangement of treatments plus control) to determine the effect of inclusion level [0 (control), 16.7, 33.3, and 50% of diet DM) and form (dry (DDGS) or modified wet (MWDGS)] of distillers’ grains plus solubles (DGS) on hepatic and renal glutathione peroxidase (GPx) and hepatic urea cycle enzyme activities. Kidney weight (g kg−1of BW) increased linearly (P=0.004) with increasing inclusion levels of DGS. There were no effects (P≥0.11) of dietary treatment on hepatic and renal GPx activity (U g−1, U mg−1of protein, and kU liver−1). Hepatic carbamoyl phosphate synthetase activity (kU liver−1and U kg−1of BW) tended to linearly increase (P=0.09 and P=0.10, respectively) with increasing inclusion level of DGS. Hepatic ornithine transcarbamoylase and argininosuccinate synthetase activity (kU liver−1and U kg−1of BW) increased linearly (P≤0.05) with increasing inclusion levels of DGS. These data indicate that steers adapt to feeding up to 50% DGS by increasing kidney mass and activity of urea cycle enzymes in liver to allow for clearance of excess nitrogen. Also, hepatic and renal GPx activity, as an indicator of Se status, is not affected when typical finishing diets are fed.

Effect of dietary crude protein level on visceral organ mass, cellularity, and the protein expression of ATP synthase, Na+/K+-ATPase, proliferating cell nuclear antigen and ubiquitin in feedlot steers

Twenty-four steers [initial body weight (BW) = 510 ± 4.9 kg] predominately of Angus breeding were used to determine the effect of dietary crude protein (CP) level [8.5, 10.7, 12.3 or 14.5%, dry matter (DM) basis; high-moisture-corn-based diets] on visceral mass, cellularity, and protein expression of ATP synthase, Na+/K+-ATPase, proliferating cell nuclear antigen (PCNA) and ubiquitin. Steers were on dietary treatment for 28 d. Kidney, liver, and reticulorumen weights (g) increased linearly (P < 0.05) with increased dietary CP. Lung weight (g; g kg-1 BW) linearly increased (P < 0.05) with increased CP. Ruminal and small intestinal DNA concentration, and the ratios of RNA:DNA and protein:DNA in small intestine were affected quadratically by increased dietary CP (P < 0.05). Hepatic ATP synthase expression was affected quadratically with an increase when dietary CP increased from 8.5 to 10.7%, and a decrease when dietary CP increased from 10.7 to 14.5% (P < 0.05). Renal ATP synthase expression decreased linearly (P < 0.05) and small intestine mucosal Na+/K+-ATPase expression increased linearly (P = 0.05) with increased CP. These results indicate that increasing dietary CP increases liver, kidney, lung, and rumen masses, and differentially influences expression of proteins influencing energy utilization and efficiency in liver, kidney, and small intestine.Key words: Dietary crude protein, visceral organ mass, cellular energy metabolism, steer

Pancreatic mass, cellularity, and alpha-amylase and trypsin activity in feedlot steers fed diets differing in crude protein concentration

Twenty-four yearling beef steers (initial BW = 510 +/- 4.9 kg) predominantly of Angus breeding were used in a randomized complete block design to determine the effect of dietary CP concentration on pancreatic cellularity, mass, and alpha-amylase and trypsin activities. Treatment diets were formulated to contain 8.8, 11.0, 13.2, and 15.4% CP. Soybean meal and Top Soy (ruminal bypass soybean meal) were used as supplemental protein sources to ensure that MP intake was increased with increasing dietary CP concentrations. Steers were penned in groups of 4 (1 steer per treatment) and individually fed at 2.5x the NE(m) requirement by using Calan gates for 28 d before tissue collection. Four steers (1 pen) were slaughtered per week. Pancreases were weighed, subsampled, frozen in liquid N(2), and stored at -80 degrees C until analyses for DNA, RNA, and protein concentrations, and alpha-amylase and trypsin activities. Pancreatic weight (g and g/kg of BW) did not differ among treatment groups. Pancreatic DNA concentration (mg/g) decreased linearly (P = 0.06) with increasing CP concentration. Pancreatic protein (g/pancreas) increased linearly (P = 0.08) with increasing dietary CP concentration. Pancreatic alpha-amylase activity (U/g, U/mg of DNA, U/g of protein, U/pancreas, and U/kg of BW) increased linearly (P < or = 0.04) with increasing dietary CP concentration. Pancreatic trypsin activity (U/g, U/g of DNA, U/g of protein, U/pancreas, and U/kg of BW) increased linearly (P < or = 0.09) with increasing dietary CP concentration. Pancreatic alpha-amylase and trypsin activities (U/mg of RNA) responded quadratically (P < or = 0.09), with the greatest alpha-amylase activity observed in the 13.2% CP treatment. These data indicate that increasing dietary CP concentration decreases pancreatic cell numbers and also increases the concentration and content of pancreatic alpha-amylase and trypsin activities. Changes in cell number and size may be important factors regulating digestive enzyme production in the pancreas of cattle.

Multi-source water pollution in the Upper Citarum watershed, Indonesia, with special reference to its spatiotemporal variation

The Citarum River in West Java is the largest water supplier to the Saguling Dam, which plays a major role in electric power generation for the entire Java Island and is used for the aquaculture of marketed fish. To elucidate the extent of degradation in water quality and its causes in the Upper Citarum watershed, physical, chemical and biological parameters for water samples collected from various sites were analyzed. The results demonstrate large site-to-site variations in water qualities and pollutant loads derived from various human activities such as agriculture, cattle raising and the textile industry. To halt worsening conditions of the Citarum watershed, integrated mitigation efforts should be made, taking biophysical pollution mechanisms and local socioeconomic conditions into account.

Cellular expression of functional chemokine receptor CCR5 and CXCR4 in human embryonic neurons

In the present study we analysed expression of the chemokine receptors CCR5 and CXCR4 in human embryonic neurons. Both receptors were detected in neurons from primary cultures by immunofluorescence and confocal laser microscopy analysis. Both CCR5 and CXCR4 were mainly located inside the cell in the neuronal cell body and processes. In addition, neurons synthesised CCR5 and CXCR4 transcripts, as demonstrated by reverse transcription-polymerase chain reaction. Stimulation with the CCR5 and the CXCR4 agonists increased [Ca(2+)](i) in embryonic neurons, indicating that CXCR4 and CCR5 were functional at the neuronal surface. The inhibitory effect of pertussis toxin demonstrated that G(i)alpha protein is involved in chemokine receptor activation. The fact that chemokine receptors are expressed at embryonic stage in neurons reinforces the idea that chemokines might be cues for neuron pathfinding during brain ontogeny.

Isolated human astrocytes are not susceptible to infection by M- and T-tropic HIV-1 strains despite functional expression of the chemokine receptors CCR5 and CXCR4

Within the brain, HIV-1 targets the microglia and astrocytes. Previous studies have reported that viral entry into astrocytes is independent of CD4, in contrast to microglia. We aimed to determine whether chemokine receptors play a role in mediating CD4-independent HIV-1 entry into astrocytes. We found that embryonic astrocytes and microglial cells express CCR5, CCR3, and CXCR4 transcripts. Intracellular calcium levels in astrocytes were found to increase following application of RANTES, MIP-1beta (CCR5-agonist), SDF-1alpha (CXCR4-agonist), but not eotaxin (CCR3-agonist). In microglial cells, eotaxin was also able to modulate internal calcium homeostasis. CD4 was not present at the cell surface of purified astrocytes but CD4 mRNA could be detected by RT-PCR. Neither HIV-1(9533) (R5 isolate) nor HIV-1(LAI) (X4 isolate) penetrated into purified astrocytes. In contrast, mixed CNS cell cultures were infected by HIV-1(9533) and this was inhibited by anti-CD4 mAb in 4/4 tested cultures and by anti-CCR5 mAb in 2/4. Thus, the HIV-1 R5 strain requires CD4 to penetrate into brain cells, suggesting that CCR5 cannot be used as the primary receptor for M-tropic HIV-1 strains in astrocytes. Moreover, inconstant inhibition of HIV-1 entry by anti-CCR5 mAb supports the existence of alternative coreceptors for penetration of M-tropic isolates into brain cells.

Activation of adenosine A1 and A2A receptors modulates dopamine D2 receptor-induced responses in stably transfected human neuroblastoma cells

Adenosine can influence dopaminergic neurotransmission in the basal ganglia via postsynaptic interaction between adenosine A2A and dopamine D2 receptors. We have used a human neuroblastoma cell line (SH-SY5Y) that was found to express constitutively moderate levels of adenosine A1 and A2A receptors (approximately 100 fmol/mg of protein) to investigate the interactions of A2A/D2 receptors, at a cellular level. After transfection with human D2L receptor cDNA, SH-SY5Y cells expressed between 500 and 1,100 fmol of D2 receptors/mg of protein. In membrane preparations, stimulation of adenosine A2A receptors decreased the affinity of dopamine D2 receptors for dopamine. In intact cells, the calcium concentration elevation induced by KCI treatment was moderate, and dopamine had no effect on either resting intracellular free Ca2+ concentration ([Ca2+]i) or KCI-induced responses. In contrast, pretreatment with adenosine deaminase for 2 days dramatically increased the elevation of [Ca2+]i evoked by KCI, which then was totally reversed by dopamine. The effects induced by 48-h adenosine inactivation were mimicked by application of adenosine A1 antagonists and could not be further reversed by acute activation of either A1 or A2A receptors. Acute application of the selective A2 receptor agonist CGS-21680 counteracted the D2 receptor-induced [Ca2+]i responses. The present study shows that SH-SY5Y cells are endowed with functional adenosine A2A and A1 receptors and that A2A receptors exert an antagonistic acute effect on dopamine D2 receptor-mediated functions. In contrast, A1 receptors induce a tonic modulatory role on these dopamine functions.