Examining the Role of Novel CKD Therapies for the ADPKD Patient.

Abstract

Two new classes of drugs, sodium-glucose cotransporter-2 inhibitors (SGLT2is) and hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitors (HIF-PHis), are likely to have a significant effect on the management of CKD. SGLT2is were approved by the Food and Drug Administration for the treatment of diabetes in 2013, and have now been shown to slow the progressive loss of kidney function in both diabetic and nondiabetic kidney disease (1⇓–3). SGLT2is demonstrate mortality benefit for patients with CKD, distinguishing them from renin-angiotensin-aldosterone system inhibitors (RAASis), which have otherwise been the mainstay of treatment for patients with diabetic or proteinuric CKD and which provide mortality benefit for a subset of patients with heart failure with reduced ejection fraction (4). Studies of SGLT2is in nondiabetic CKD have been extremely encouraging and we expect that these medications will soon become standard of care for diabetic or nondiabetic, and proteinuric or nonproteinuric, CKD. The potential benefits of SGLT2is have not been specifically explored in autosomal dominant polycystic kidney disease (ADPKD), because both major trials of SGLT2is in nondiabetic CKD (the ongoing EMPA-KIDNEY study [5] and the recently published DAPA-CKD study [1]) excluded patients with ADPKD. Separately, HIF-PHis are anticipated to have a major effect in the management of anemia of CKD. The current use of erythropoiesis-stimulating agents (ESAs) involves a complex balance between treating anemia and limiting potential adverse effects of cardiovascular events, hypertension, and loss of vascular access (6). HIF-PHis have beneficial effects on iron metabolism, hypertension, and inflammation (7). However, there are concerns that HIF activation could promote cyst growth (8) when used for treatment of patients with ADPKD. Here, we examine reasons why patients with ADPKD, who comprise approximately 5% of the ESKD population in the United States, warrant unique consideration regarding treatment with SGLT2is or HIF-PHis. We …