Sodium-glucose Cotransporter 2 Inhibitor Treatment Research Articles

Ventricular arrhythmia events in patients with implantable cardioverter-defibrillator before and after the treatment with sodium-glucose co-transporter 2 inhibitors

Abstract Background The role of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in the treatment of chronic heart failure is expanding. However, the timing of implantable cardioverter-defibrillator (ICD) implantation for primary prevention in relation to the use of SGLT2i remains unclear. A small case series has described appropriate shocks from ICD in two patients following the initiation of SGLT2i, but a comprehensive analysis is lacking in the literature. Methods This study aimed to investigate the rate of ventricular arrhythmic burden and appropriate anti-tachycardia therapy from ICD before and after the initiation of SGLT2i therapy. We conducted a retrospective single-center analysis, comparing ventricular events from home monitoring reports three months before and three months after SGLT2i therapy initiation. Results Seventeen patients were enrolled in the study. At baseline, clinical characteristics were as follows: 13 (76%) were male, 9 (53%) had ischemic, 2 (12%) had valvular, and 6 (35%) had idiopathic cardiomyopathy. The mean end-diastolic volume (EDV) was 203 ± 90 ml, and the mean left ventricular ejection fraction was 0.36 ± 0.09. All patients were treated with beta-blockers, 14 (82%) with sacubitril-valsartan, 13 (76%) with aldosterone antagonists, 16 (94%) with furosemide, and 5 (29%) with amiodarone. SGLT2i started with dapagliflozin for 13 patients (76%), empagliflozin for 3 patients (18%), and canagliflozin for 1 patient (6%). Ten patients (59%) had single-chamber or dual-chamber ICDs, and 7 had implantable cardiac resynchronization therapy (CRT) defibrillators. In the three months before SGLT2i treatment, 4/17 patients had non-sustained ventricular tachycardia (NSVT), compared to 8/17 (23% vs. 47%, p-value 0.23) patients with NSVT after treatment. Seven patients (41%) experienced an increase in the rate of NSVT events, with one patient having 28 NSVT events after treatment versus none before treatment. No patients had anti-tachycardia therapy in the three months before treatment, while in the three months after SGLT2i treatment, 1 patient had ventricular tachycardia treated with anti-tachycardia pacing (110 days after the beginning of the treatment), and 2 patients had ventricular tachycardia treated with appropriate shocks (2 and 25 days after the initiation of SGLT2i treatment). Conclusion This small retrospective analysis revealed an increase in ventricular arrhythmic events in the three months following the initiation of SGLT2i. These findings highlight the need for a more extensive analysis to establish a stronger statistical correlation.

#1392 MEST-C score correlation with proteinuria reduction after SGLT2i treatment in patients with IgA nephropathy

Abstract Background and Aims Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with better cardiovascular outcomes and with nephroprotection independent of diabetes status. Recent data suggest that SGLT2i significantly reduce proteinuria in patients with IgA nephropathy (IgAN). Data available for the use of the MEST-C score to determine if treatment would benefit IgAN patients is scarce. The aim of our study was to assess the degree of proteinuria reduction after SGLT2i treatment in IgAN and its possible association with the MEST-C score. Method 63 adult patients with biopsy-proven IgA nephropathy, eGFR ≥ 30 mL/min/1.73 m2 (CKD-epi), and total urine protein of >0.5 grams/day at screening were included. Patients with secondary IgAN and crescents were excluded. All receiving maximally tolerated RASi for at least 12 weeks. All patients started dapagliflozin 10 mg once per day after baseline data were registered. The total follow-up was 12 months. The main outcome was the decline in eGFR and the reduction in 24-hour proteinuria from SGLT2i initiation to 1,3, 6, 9, 12 months, end-stage renal disease, or kidney or cardiovascular death. Three repeated measurements of proteinuria (mg/24H) were performed, 90 days before SGLT2i treatment initiation, and only patients with stable proteinuria were enrolled in the study. Results 49 patients (35/14 M/F), with mean age of 41,9 ± 19,6 years, completed follow up. 8 patients discontinued treatment due to adverse events attributed to dapagliflozin. At baseline eGFR was 68.21±18,1 ml/min/1.73 m2 and Upr: 2196±1091 mg/24H. The MEST-C scores were correlated with the serum creatinine level, proteinuria, and hematuria. The mean serum creatinine level was higher in M1, E1, S1, and T1 compared with score “0”. It was statistically significant (p = 0.03) only in the T-score. The mean proteinuria level was again higher in M1, S1, and T1 but reached statistical significance (p = 0.037) in only the T1-score. E1 has higher hematuria. The Upr/24H difference for dapagliflozin was −24.7% (95% CI −27.5, −23.2; p < 0.001) at the end of follow-up (month 12). Proteinuria reduction was similar across all eGFRs, age, and baseline proteinuria. Among MEST-C score parameters, T1 had a negative impact on the antiproteinuric effect of dapagliflozin (p = 0.01) No hypoglycemic events were reported and no deaths occurred. Conclusion In the present study, the use of SGLT2i was associated with a significant reduction of proteinuria in patients with IgA nephropathy and maximally tolerated RASi. We analyzed renal outcomes in association with pathologic features. We established that the presence of the T1 score has a negative impact on proteinuria reduction after SGLT2i treatment. Further studies are needed to investigate the impact of the use of the Oxford Classification score for developing individual treatment therapies.

#1679 Relationship between initial eGFR DIP with proteinuria after SGLT2i treatment, in patients with IgA nephropathy. A real-world clinical study

Abstract Background and Aims Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with better cardiovascular outcomes and with nephroprotection independent of diabetes status. Recent data suggest that SGLT2i significantly reduce proteinuria in patients with IgA nephropathy (IgAN). However, they often cause an initial decline in estimated glomerular filtration rate (eGFR). The aim of our study was to assess the degree of proteinuria reduction after SGLT2i treatment in IgAN and its possible association with the initial functional dip in eGFR. Method 63 adult patients with biopsy-proven IgA nephropathy, eGFR ≥ 30 mL/min/1.73 m2 (CKD-epi), and total urine protein of >0.5 grams/day at screening were included. Patients with secondary IgAN were excluded. All receiving maximally tolerated RASi for at least 12 weeks. All patients started dapagliflozin 10 mg once per day after baseline data were registered. The total follow-up was 12 months. The main outcome was the decline in eGFR and the reduction in 24-hour proteinuria from SGLT2i initiation to 1,3, 6, 9, 12 months, end-stage renal disease, or kidney or cardiovascular death. Results 55 patients (38/17 M/F), with mean age of 44,2±18,3 years, completed follow up. 8 patients discontinued treatment due to adverse events attributed to dapagliflozin. At baseline eGFR was 66.17±19,7 ml/min/1.73 m2 and Upr: 2356±1023 mg/24H. There was a transient decline in eGFR, 30 days after initiation of dapagliflozin (66.17±19,7 min/1.73 m2 at baseline to 57 ml/min/1.73 m2) but then, there was an improvement at month 3 from baseline. The Upr/24H difference for dapagliflozin was −25.1% (95% CI −27.5, −23.2; p < 0.001) at the end of follow-up (month 12). Proteinuria reduction was similar across all eGFRs. Notably, a significant correlation was found between the initial eGFR dip and percentage proteinuria reduction in the 12th month. (R = –0.23; p = 0.03). Consistent results of dapagliflozin treatment on proteinuria were found in all analysis subgroups including sex, baseline proteinuria, systolic blood pressure, and body mass index. No hypoglycaemic events were reported and no deaths occurred. Conclusion In the present study, the use of SGLT2i was associated with a significant reduction of proteinuria in patients with IgA nephropathy in patients with maximally tolerated RASi. Higher initial eGFR dip after treatment initiation was a predictor of a significantly higher reduction in proteinuria at the end of follow-up. The correlation between eGFR dip and proteinuria reduction perhaps reflects the intraglomerular pressure reduction, mediated by tubuloglomerular feedback, one of the numerous.

#1626 The role of sodium-glucose cotransporter 2 inhibitors in diabetic nephropathy and non diabetic renal disease in diabetes mellitus type 2 patients

Abstract Background and Aims Diabetes Mellitus type 2 (DM2) leads to chronic kidney disease in a 30-40% of diabetic patients and it is the major cause of end stage renal disease (ESRD). The clinical course of diabetic kidney disease is very heterogeneous and there is a lack of agreement between clinical parameters and renal histology. Besides, lesions of non-diabetic kidney disease (NDRD) can coexist with lesions of diabetic nephropathy (DN) in two-thirds of kidney biopsies in patients with diabetes. There is not a specific treatment against diabetic kidney disease, treatment based in the blockade of renin-angiotensin-aldosterone system has demonstrated a delay of kidney function decline but the diabetic kidney disease is still the main cause of renal replacement by dialysis. Recently, a new class of oral glucose -lowering drugs, sodium-glucose cotransporter 2 (SGLT2) inhibitors, have shown beneficial effects into cardiovascular protection and chronic kidney disease in diabetic patients but it is not clear the beneficial effect in DN. The aim of this study is to evaluate the role of SGLT2 inhibitors in diabetic patients with DN biopsy-confirmed and compare with a group of diabetic patients with NDRD (DN and superimposed non diabetic renal disease lesions, NDRD). Method This is a retrospective study with DM2 patients and kidney biopsy performed. Patient demographic characteristics were recorded and diagnosis of Hypertension, duration of DM2, presence or absence of diabetic retinopathy (DR), macrovascular disease and treatment with renin–angiotensin– aldosterone system blockers (RAASB), oral hypoglycaemic agents, insulin, and aldosterone antagonists. Histological lesions were recorded according to the pathologic classification of DN. Renal function was based on estimated filtration rate CKD-EPI (eGFR mil/min/m2), the urine albumin-creatinine ratio (UACR mg/gr) and the 24 h proteinuria (g/24 h). Diabetic patients were classified according to the kidney biopsies in DN and NDRD. The follow up was assessed at the time of sodium-glucose cotransporter 2 (SGLT2) inhibitors started, 6, 12 and 24 months. Results A total of 64 DM2 patients with kidney biopsy were included in the study. Basal characteristics are summarized in Table 1. DN was diagnosed in 47% and NDRD in 53% of DM2 patients. DM2 patients with NDRD were older (64 ± 10 vs 70 ± 10, p = 0.017), and with more macrovascular disease than patients with DN, 6 (20%) vs 15 (44%), p = 0.04. Instead, DM2 patients with DN showed higher uACR levels than NDRD (2355 ± 2540 vs 706 ± 730, p = 0.02). A 40% of DM2 patients with DN were classified in nodular sclerosis class III of glomerular classification of DN. Interstitial fibrosis and tubular atrophy score were higher in DN versus NDRD patients, (interstitial fibrosis 12 (40%) vs 3 (9%), p = 0.006, tubular atrophy 10 (33%) vs 3 (9%), p = 0.02, Table 2. At the end of follow up, 20% of DM2 patients developed ESRD. According SGLT2 inhibitors treatment, a higher proportion of ESRD and death were observed in DM2 patients without SGLT2 inhibitors than patients with SGLT2 inhibitors, ESRD 11 (39%) vs 2 (6%), p = 0.001, death 9 (32%) vs 4 (11%), p = 0.03. Serum creatinine levels were lower in DM2 patients with SGLT2 inhibitors (118 ± 63.7 vs 203 ± 80.7, p = 0.001), but no differences was observed in uACR between groups. A significant reduction in serum creatinine levels with better eGFR were observed in both groups (DN and NDRD) under SGLT2 inhibitors comparing to group without SGLT2 inhibitors, serum creatinine levels 124 ± 78 vs 236 ± 83, p = 0.008, 107 ± 40 vs 201 ± 110, p = 0.02, and eGFR mil/min/m2 60.9 ± 27.5 vs 25.1 ± 7.2, p = 0.004, 62.6 ± 21.2 vs 33.7 ± 16.2, p = 0.005, Table 3. Conclusion A higher proportion of DM2 showed NDRD lesions in kidney biopsy. Treatment with SGLT2 inhibitors reduced progression of chronic renal disease in DN and NDRD DM2 patients. A reduced progression to ESRD and death were also observed in NDRD DM2 patients with SGLT2 treatment.

#646 SGLT2 inhibitor alleviates hypomagnesemia in patients with chronic kidney disease: a retrospective observational study

Abstract Background and Aims Magnesium (Mg2+) is a critical component in numerous biological processes. Hypomagnesemia is associated with an increased risk of cardiovascular events and vascular calcification in individuals with and without chronic kidney disease (CKD). Sodium-glucose cotransporter-2 (SGLT2) inhibitors have been proposed for treating CKD, based on their reported benefits to the kidney and cardiovascular system and in increasing serum Mg2+ levels in patients with type 2 diabetes mellitus. However, the underlying mechanisms remain unclear. In this retrospective observational study, we aimed to investigate the changes in serum Mg2+ levels after administering SGLT2 inhibitors and to identify factors contributing to these changes. Method We retrospectively examined 57 patients with CKD who received treatment at Wakayama Medical University between January 1, 2017, and December 31, 2022. We assessed changes in serum Mg2+ levels at baseline and 1, 3, and 6 months post-treatment. Patients were stratified into tertiles based on baseline Mg2+ levels. Multivariate regression analyses were conducted to identify factors associated with changes in Mg2+ levels. Results SGLT2 inhibitor treatment was associated with a significant increase in serum Mg2+ levels in the low and intermediate tertiles but not in the high tertile. Multivariate analysis revealed that gender, baseline serum Mg2+, and sodium-chloride difference were independent predictors of the increase in serum Mg2+ levels. Conclusion SGLT2 inhibitor treatment in CKD patients is associated with an increase in serum Mg2+ levels, particularly in those with lower baseline levels. The serum Mg2+-improving effect of SGLT2 inhibitors is influenced by baseline serum Mg2+ levels, sodium-chloride difference, and gender. These findings suggest the potential utility of SGLT2 inhibitors for treating hypomagnesemia in CKD.

#2175 Sodium-glucose cotransporter 2 (SGLT2) inhibitors-induced erythropoiesis and cardiovascular events in chronic kidney patients

Abstract Background and Aims Prior research has established that in chronic kidney disease (CKD), elevating hemoglobin (Hb) levels above 11.5 g/dl correlates with heightened thromboembolic event risks and increased mortality. Similar findings are seen in heart failure patients with Hb levels exceeding 13 g/dl, following treatment with erythropoiesis-stimulating agents. Sodium-glucose cotransporter 2 (SGLT2) inhibitors consistently raise Hb levels in CKD patients, both anemic and non-anemic. This study aims to evaluate the consequences of Hb level elevation due to SGLT2 inhibitors beyond the safe threshold in CKD patients and to investigate its association with cardiovascular (CV) events. Method A retrospective observational study was conducted from January 2016 to December 2021, focusing on CKD patients treated with SGLT2 inhibitors. Patients receiving erythropoiesis-stimulating agents or undergoing renal replacement therapy were excluded. We assessed the impact of Hb level changes on atheroembolic events, blood pressure variations, and mortality, while considering demographic data, red blood cell parameters, and renal function indicators. Patients receiving iron treatment were excluded to ensure accurate ferrokinetic parameter assessment. Results The study included 79 CKD patients, predominantly male (76%) and primarily with type 2 diabetes mellitus (T2DM) as the CKD cause (67%). Average follow-up post-SGLT2 inhibitor initiation was 3.5 years (SD 1.4, 0.7-6.7 years). Hb levels increased mainly in the first six months of treatment, with an average increase of 0.7 g/dl/year from baseline (p < 0.01). Ferritin levels slightly decreased (p 0.002), while the transferrin saturation index remained stable. Baseline estimated glomerular filtration rate (eGFR) did not influence Hb increase. Various responses to SGLT2 inhibitors were noted based on baseline Hb levels. No significant association was found between elevated Hb levels (>16.0 g/dl) and increased atheroembolic events, mortality, or blood pressure changes. However, patients with Hb levels >13.0 g/dl experienced more CV events compared to those maintaining Hb ≤13.0 g/dl, though not statistically significant (0% vs 17.5%: p 0.30). Conclusion SGLT2 inhibitor treatment led to a significant Hb increase unless baseline levels were above 16.0 g/dl. Importantly, elevating Hb levels above 13.0 g/dl appears to be linked with a higher incidence of cardiovascular (CV) events, suggesting a potential risk associated with such an increase in Hb levels in this patient population. This finding underscores the necessity for further research to confirm this correlation and to delineate the safe therapeutic window for Hb levels in CKD patients treated with SGLT2 inhibitors.

#60 Implementation of chronic kidney disease guidelines for sodium-glucose co-transporter-2 inhibitor use in primary care: a cross-sectional study

Abstract Background and Aims The cardiovascular and kidney benefits of sodium-glucose co-transporter-2 (SGLT2) inhibitors in people with chronic kidney disease (CKD) are well established. The implementation of updated SGLT2 inhibitor guidelines and prescribing in the real-world CKD population remains largely unknown. Method We performed a cross-sectional study of adults with CKD registered with primary care practices in the Oxford-Royal College of General Practitioners Research and Surveillance Centre network on the 31st December 2022. We examined the extent to which SGLT2 inhibitor guidelines apply to and are then implemented in adults with CKD. We used a logistic regression model to identify independent factors associated with SGLT2 inhibitor prescribing. Results Of 6,670,829 adults we identified 516,491 (7·7%) with CKD, including 32·8% (n = 169,443) who had co-existing type 2 diabetes (T2D). 26·8% (n = 138,183) of the overall CKD population had a guideline directed indication for SGLT2 inhibitor treatment. A higher proportion of CKD patients with co-existing T2D were indicated for treatment, compared to those without T2D (62·8% [n = 106,468] vs. 9·1% [n = 31,715]). SGLT2 inhibitors were prescribed to 17·0% (n = 23,466) of those with an indication for treatment, and prescriptions were predominantly in those with co-existing T2D; 22·0% (n = 23,464) in those with T2D, and <0·1% (n = 2) in those without T2D. In adjusted multivariable analysis of people with CKD and T2D, females (OR 0·70, 95% CI 0·67-0·72, p < 0·001), individuals of Black ethnicity (OR 0·87, 95% CI 0·79-0·95, p < 0·001) and those of lower socio-economic status (OR 0·71, 95% CI 0·68-0·75, p < 0.001) were less likely to be prescribed an SGLT2 inhibitor. Those with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 had a lower likelihood of receiving an SGLT2 inhibitor compared to those with an eGFR ≥60 mL/min/1.73 m2 (eGFR 45-60 mL/min/1·73 m2 OR 0·65, 95% CI 0·62-0·68, p < 0·001, eGFR 30-45 mL/min/1·73 m2 OR 0·73, 95% CI 0·69-0·78, p < 0·001, eGFR 15-30 mL/min/1·73 m2 OR 0·52, 95% CI 0·46-0·60, p < 0·001, eGFR <15 mL/min/1·73 m2 OR 0·03, 95% CI 0·00-0·23, p = 0·004, respectively). Those with albuminuria (urine albumin-to-creatinine ratio 3-30 mg/mmol) were less likely to be prescribed an SGLT2 inhibitor, compared to those without albuminuria (OR 0·78, 95% CI 0·75-0·82, p < 0·001). Conclusion SGLT2 inhibitor guidelines in CKD have not yet been successfully implemented into clinical practice, most notably in those without co-existing T2D. Enhanced efforts to embed SGLT2 inhibitors equitably into routine care for people with CKD are urgently needed, particularly in those at highest risk of adverse outcomes and in the absence of T2D.

Effect of preceding drug therapy on the renal and cardiovascular outcomes of combined sodium-glucose cotransporter-2 inhibitor and glucagon-like peptide-1 receptor agonist treatment in patients with type 2 diabetes and chronic kidney disease.

To conduct a post hoc subgroup analysis of patients with type 2 diabetes (T2D) from the RECAP study, who were treated with sodium-glucose cotransporter-2 (SGLT2) inhibitor and glucagon-like peptide 1 receptor agonist (GLP-1RA) combination therapy, focusing only on those patients who had chronic kidney disease (CKD), to examine whether the composite renal outcome differed between those who received SGLT2 inhibitor treatment first and those who received a GLP-1RA first. We included 438 patients with CKD (GLP-1RA-first group, n = 223; SGLT2 inhibitor-first group, n = 215) from the 643 T2D patients in the RECAP study. The incidence of the composite renal outcome, defined as progression to macroalbuminuria and/or a ≥50% decrease in estimated glomerular filtration rate (eGFR), was analysed using a propensity score (PS)-matched model. Furthermore, we calculated the win ratio for these composite renal outcomes, which were weighted in the following order: (1) both a ≥50% decrease in eGFR and progression to macroalbuminuria; (2) a decrease in eGFR of ≥50% only; and (3) progression to macroalbuminuria only. Using the PS-matched model, 132 patients from each group were paired. The incidence of renal composite outcomes did not differ between the two groups (GLP-1RA-first group, 10%; SGLT2 inhibitor-first group, 17%; odds ratio 1.80; 95% confidence interval [CI] 0.85 to 4.26; p = 0.12). The win ratio of the GLP-1RA-first group versus the SGLT2 inhibitor-first group was 1.83 (95% CI 1.71 to 1.95; p < 0.001). Although the renal composite outcome did not differ between the two groups, the win ratio of the GLP-1RA-first group versus the SGLT2 inhibitor-first group was significant. These results suggest that, in GLP-1RA and SGLT2 inhibitor combination therapy, the addition of an SGLT2 inhibitor to baseline GLP-1RA treatment may lead to more favourable renal outcomes.

VENTRICULAR ARRHYTHMIA EVENTS IN PATIENTS WITH IMPLANTABLE CARDIOVERTER–DEFIBRILLATOR BEFORE AND AFTER THE TREATMENT WITH SODIUM–GLUCOSE CO–TRANSPORTER 2 INHIBITORS

Abstract Background Role of sodium–glucose co–transporter 2 inhibitors (SGLT2i) in the treatment of chronic heart failure is increasing. However, some case series described appropriate shocks from ICD in patients following the initiations of SGLT2i and a larger analysis is not present in the literature. Methods The aim of this study is to investigate the rate of ventricular arrhythmic burden and appropriate anti–tachycardia therapy from ICD before and after the initiation of SGLT2i therapy. A retrospective single–center analysis was performed, comparing ventricular events from home monitoring reports 3 months before and 3 months after SGLT2i therapy treatment. Results Seventeen patients were enrolled in the study. The baseline clinical e therapy characteristics of patients are shown in the table. Ten patients (59%) had mono cameral or dual cameral ICD and 7 had implantable cardiac resynchronization therapy (CRT) defibrillators.During the 3 months before SGLT2i treatment, 4/17 patients had nun–sustained ventricular tachycardia (NSVT) vs 8/17 (23% vs 47%, P value 0.23) patients with NSTV after the treatment. Seven patients (41%) had an increase in the rate of NSVT events (with a patient with 28 NSVT after treatment vs 0 before treatment). No patients had anti–tachycardia therapy in the 3 months before treatment, while during the 3 months after the SGLT2i treatment, 1 patient had a ventricular tachycardia treated with anti–tachycardia pacing (110 days after the beginning of the treatment) and 2 patients had a ventricular tachycardia treated with appropriate shock (2 and 25 days after the beginning of SGLT2i treatment). Conclusion This small retrospective analysis showed an increase in ventricular arrhythmic events in the 3 months after the initiation of SGLT2i. These data prospect the need for a larger analysis for a stronger statistical correlation.

SGLT2i IN THE REAL WORLD: DATA FROM THE PONTE (bridge) HF PROJECT (PDTA FOR INTEGRATED TERRITORY HOSPITAL FOLLOW-UP OF PATIENTS WITH HEART FAILURE)

Abstract Background Over the last few years, treatment with sodium glucose cotransporter 2 inhibitors (SGLT2i) dapaglifozin and empaglifozin was shown to reduce the combined risk of cardiovascular death and/or hospitalization for heart failure (HF) among patients with heart failure with reduced ejection fraction. Subsequent RCTs have demonstrated similar reduction in the combined endpoint also in patients with left ventricular ejection fraction (LVEF) &amp;gt;40%. Nevertheless, real world data on the current state of implementation of SGLT2i therapy in HF clinical practice are scarce. The aim of the study was therefore to evaluate the impact of SGLT2i treatment in a real world population of HF patients. Methods 527 consecutive patients with HF, treated with SGLT2i and with 6 months of follow-up already enrolled in the PONTE (PDTA FOR THE INTEGRATED FOLLOW-UP IN THE HOSPITAL TERRITORY OF THE PATIENT WITH HEART FAILURE) HF project, a care model implemented in Puglia region (Italy) based on hospital-territory integration aimed at the optimized management of patient with HF after hospitalization, were considered for the study. Demographic, clinical, laboratory and instrumental characteristics, changes in NYHA class, creatinine, NT-proBNP, medications, LVEF after initiation of therapy with SGLT2i were evaluated. Results The 527 enrolled patients (mean age of 67,40 years, 75% hypertensive, 39% diabetic, 51% ischemic heart disease, 52% with ICD, 35% with atrial fibrillation) were in NYHA class I in 3,2% of cases, class II in 56,6%, class III in 38,5%, class IV in 1,7%. Mean LVEF was 34,20% (63% of patients had LVEF &amp;lt;35%), NT-proBNP 2606,86 pg/ml, creatinine 1,19 mg/dl. 95,1% of patients was on treatment with beta-blockers, 52,7% with ACE inhibitors, 55,1% with ARNI. After a follow-up of 6 months, a reduction of patients in NYHA classes III+IV from 40,2 to 19,0% as well as an increase in patients in classes I+II from 59,8 to 81,0% (NYHA I increasing from 3,2 to 14,6%) were observed. Furthermore, mean LVEF increased from 34,20 to 37,68% and patients taking loop diuretics reduced from 83,9 to 77,4%. Creatinine remained stable (1,19 vs 1,21 mg/dl), while NT-proBNP lowered from 2606,86 to 1603,32 pg/ml. Conclusions Our real world data on SGLT2i in HF patients seem to confirm the efficacy of this class of drugs in a short term follow-up, with a positive effect on symptoms (improvement in NYHA class and fewer patients taking loop diuretics), NT-proBNP and LVEF.

Ketonuria as an Indicator of Improvement of Renal Function in Patients with Type 2 Diabetes Receiving SGLT2 Inhibitor Treatment.

We investigated the potential association between ketonuria during treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors and its renoprotective effect in patients with type 2 diabetes. We included 192 patients who had received SGLT2 inhibitors for more than 6 months. After propensity score matching, 52 patients each were allocated into groups with or without ketonuria, respectively. The estimated glomerular filtration rate exhibited a significant improvement only in subjects with ketonuria (without ketonuria: mean difference, -0.02 mL/min/1.73 m2 [95% confidence interval (CI), -3.87 to 3.83 mL/min/1.73 m2] vs. with ketonuria: mean difference, 6.81 mL/min/1.73 m2 [95% CI, 3.16 to 10.46 mL/min/1.73 m2]; P<0.001). Improvement in estimated glomerular filtration rate at 6 months was associated with female sex and lower baseline body weight, blood pressure, and triglyceride levels in patients with ketonuria. In conclusion, the presence of ketonuria was associated with the renoprotective effect of SGLT2 inhibitors, and female sex and the absence of metabolic syndrome components may serve as additional indicators of these medications' substantial renoprotective effects in individuals with ketonuria.

Exercise Training Mitigates Inhibition of Skeletal Muscle Mitochondrial Respiration with Empagliflozin Treatment in Male and Female Mice

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are antihyperglycemic drugs designed to lower renal glucose reabsorption, yet recent evidence indicates that SGLT2i have off-target effects on skeletal muscle to inhibit mitochondrial respiration. Such inhibition raises important questions regarding the interaction of SGLT2i and exercise on regulation of skeletal muscle mitochondrial metabolism. The purpose of the current study was to test the hypothesis that SGLT2i treatment (empagliflozin, EMPA) would blunt improvements to skeletal muscle mitochondrial oxidation capacity following aerobic training. Male and female C57BL/6J mice consumed a western diet (40% kcal from fat) for 8 weeks, then performed an additional 8 weeks of either treadmill training (5 times per week progressing up to 23 m/min) or remained sedentary. During the intervention period, all mice consumed either western diet or western diet enriched with EMPA (10mg/kg diet) in a 2x2 design (n=10/group for each sex). We isolated mitochondria from quadriceps muscles collected 72 hours after the final training session (or rest) and measured ex vivo mitochondrial substrate oxidation capacity using high-resolution respirometry. There was an interaction between exercise and EMPA (p=0.037) on complex I-II respiration whereby sedentary mice had lower respiration following EMPA versus untreated (-17% p=0.01) while exercise-trained mice had similar respiration between EMPA and untreated. The interaction was less prominent in complex I-supported respiration (p=0.06) or complex-II alone (p=0.09). Our results show that, contrary to expectations, EMPA treatment did not impair mitochondrial adaptations to exercise training. Instead, exercise training prevented the suppression of mitochondrial respiration during EMPA treatment. These findings indicate that aerobic exercise has positive effects on the off-target inhibition of mitochondrial respiration by SGLT2i. Supported by funding from the Collins Medical Trust (Wilsonville, Oregon) awarded to Matthew Robinson. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Initial eGFR Changes with SGLT2 Inhibitor in Patients With Type 2 Diabetes and Associations With the Risk of Abnormal Serum Potassium Level.

Both high and low levels of serum potassium measurements are linked with a higher risk of adverse clinical events among patients with type 2 diabetes. The study was aimed at evaluating the implications of the various degrees of initial estimated glomerular filtration rate (eGFR) change on subsequent serum potassium homeostasis following sodium-glucose cotransporter-2 inhibitor (SGLT2i) initiation among patients with type 2 diabetes. We used medical data from a multicenter health care provider in Taiwan and recruited 5529 patients with type 2 diabetes with baseline/follow-up eGFR data available after 4 to 12 weeks of SGLT2i treatment from June 1, 2016, to December 31, 2018. SGLT2i treatment was associated with an initial mean (SEM) eGFR decline of -3.5 (0.2) mL/min per 1.73 m2 in overall study participants. A total of 36.7% (n=2028) of patients experienced no eGFR decline, and 57.9% (n=3201) and 5.4% (n=300) of patients experienced an eGFR decline of 0% to 30% and >30%, respectively. Patients with an initial eGFR decline of >30% were associated with higher variability in consequent serum potassium measurement when compared with those without an initial eGFR decline. Participants with a pronounced eGFR decline of >30% were associated with a higher risk of hyperkalemia ≥5.5 (adjusted hazard ratio,4.59 [95% CI, 2.28-9.26]) or use of potassium binder (adjusted hazard ratio, 2.65 [95% CI, 1.78-3.95]) as well as hypokalemia events <3.0 mmol/L (adjusted hazard ratio, 3.21 [95% CI, 1.90-5.42]) or use of potassium supplement (adjusted hazard ratio, 1.87 [95% CI, 1.37-2.56]) following SGLT2i treatment after multivariate adjustment. Physicians should be aware that the eGFR trough occurs shortly, and consequent serum potassium changes following SGLT2i initiation.

The Effect of SGLT2 Inhibitor Therapy on Endothelial Progenitor Cell Function in Patients with Heart Failure

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been shown to reduce the risk of cardiovascular mortality and hospitalizations in patients with heart failure (HF) with preserved or reduced ejection fraction (HFpEF or HFrEF). The mechanism for this benefit is not clear. Endothelial progenitor cells (EPCs) are bone-marrow derived cells able to differentiate into functional endothelial cells and participate in endothelial repair. The aim of the current study was to evaluate the effect of SGLT-2 inhibitors on the level and function of EPCs in patients with HF. We enrolled 20 patients with symptomatic HF, 12 with HFrEF and 8 with HFpEF (aged 73.3±10.2 years, 95% men). Blood samples were drawn at 2 time points: baseline and ≥3 months after initiation of SGLT-2 inhibitor therapy. Circulating EPC levels were evaluated by expression of VEGFR-2, CD34 and CD133 by flow-cytometry. EPCs colony forming units (CFUs) were quantified after 7 days in culture. The proportion of cells that co-expressed VEGFR-2 and CD34 or VEGFR-2 and CD133 was higher following 3 months of SGLT-2 inhibitors [0.26% (IQR 0.10-0.33) vs. 0.55% (IQR 0.28-0.91), P=0.002; 0.12% (IQR 0.07-0.15) vs. 0.24% (IQR 0.15-0.39), P=0.001, respectively]. EPCs-CFU were also increased following SGLT-2 inhibitor treatment [23 (IQR 3.7-37.8) vs. 79.4 (IQR 25.1-110.25) colonies/106 cells, P=0.0039]. In patients with symptomatic HF, both HFpEF and HFrEF, treatment with SGLT-2 inhibitors is associated with an increase in circulating EPCs level and function. This augmentation in EPCs may be a contributing mechanism to the clinical benefit of SGLT-2 inhibitors in HF patients.

The effect of sodium-glucose co-transporter 2 inhibitors on outcomes after cardiac resynchronization therapy.

The trials upon which recommendations for the use of cardiac resynchronization therapy (CRT) in heart failure used optimal medical therapy (OMT) before sodium-glucose co-transporter 2 inhibitors (SGLT2i). Moreover, the SGLT2i heart failure trials included only a small proportion of participants with CRT, and therefore, it remains uncertain whether SGLT2i should be considered part of OMT prior to CRT. We compared electrocardiogram (ECG) and echocardiographic responses to CRT as well as hospitalization and mortality rates in consecutive patients undergoing implantation at a large tertiary centre between January 2019 to June 2022 with and without SGLT2i treatment. Three hundred seventy-four participants were included aged 74.0±11.5years (mean±standard deviation), with a left ventricular ejection fraction (LVEF) of 31.8±9.9% and QRS duration of 161±29ms. The majority had non-ischaemic cardiomyopathy (58%) and were in NYHA Class II/III (83.6%). These characteristics were similar between patients with (n=66) and without (n=308) prior SGLT2i treatment. Both groups demonstrated similar evidence of response to CRT in terms of QRS duration shortening, and improvements in LVEF, left ventricular end-diastolic inner-dimension (LVIDd) and diastolic function (E/A and e/e'). While there was no difference in rates of hospitalization (for heart failure or overall), mortality was significantly lower in patients treated with SGLT2i compared with those who were not (6.5 vs. 16.6%, P=0.049). We observed an improvement in mortality in patients undergoing CRT prescribed SGLT2i compared with those not prescribed SGLT2i, despite similar degrees of reverse remodelling. The authors recommend starting SGLT2i prior to CRT implantation, where it does not delay implantation.

SGLT2 Inhibitors, Functional Capacity, and Quality of Life in Patients With Heart Failure

The associations of sodium glucose cotransporter-2 inhibitors (SGLT2is) with reduction in mortality and hospitalization rates in patients with heart failure (HF) are well established. However, their association with improving functional capacity and quality of life (QOL) has been variably studied and less reported. To provide evidence on the extent to which SGLT2is are associated with improvement on objective measures of functional capacity and QOL in patients living with HF. The MEDLINE, EMBASE, and Cochrane databases were systematically searched for relevant articles on July 31, 2023. Randomized, placebo-controlled clinical trials reporting the effect of SGLT2i on functional outcomes of exercise capacity (peak oxygen consumption [peak VO2] or 6-minute walk distance [6MWD]) and/or QOL using validated questionnaires for patients with HF were included. Data were extracted by 2 authors following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, and a meta-analysis using the restricted maximum likelihood random-effects model was conducted. Outcomes of interest included changes in peak VO2, 6MWD, and Kansas City Cardiomyopathy Questionnaire-12 total symptom score (KCCQ-TSS), clinical summary score (KCCQ-CSS), and overall summary score (KCCQ-OSS). In this meta-analysis of 17 studies, 23 523 patients (mean [range] age, 69 [60-75] years) were followed over a period ranging from 12 to 52 weeks. Four studies included peak VO2 as an outcome, 7 studies included 6MWD, and 10 studies reported KCCQ scores. Mean (SD) left ventricular ejection fraction was 43.5% (12.4%). Compared with controls, patients receiving SGLT2i treatment experienced significant increases in peak VO2 (mean difference [MD], 1.61 mL/kg/min; 95% CI, 0.59-2.63 mL/kg/min; P = .002) and 6MWD (MD, 13.09 m; 95% CI, 1.20-24.97 m; P = .03). SGLT2i use was associated with increased KCCQ-TSS (MD, 2.28 points; 95% CI, 1.74-2.81 points; P < .001), KCCQ-CSS (MD, 2.14 points; 95% CI, 1.53-2.74 points; P < .001), and KCCQ-OSS (MD, 1.90 points; 95% CI, 1.41-2.39 points; P < .001) scores. Subgroup analysis and meta-regression demonstrated almost all improvements were consistent across ejection fraction, sex, and the presence of diabetes. These findings suggest that in addition to known clinical associations with mortality and hospitalization outcomes, SGLT2i use is associated with improvement in outcomes of interest to patients' everyday lives as measured by objective assessments of maximal exercise capacity and validated QOL questionnaires, regardless of sex or ejection fraction.

Contrast-Induced Acute Kidney Injury in Patients with Heart Failure on Sodium-Glucose Cotransporter-2 Inhibitors Undergoing Radiocontrast Agent Invasive Procedures: A Propensity-Matched Analysis.

(1) Background: This single-center retrospective study aimed to evaluate whether sodium-glucose cotransporter-2 inhibitors (SGLT2-i) therapy may have a nephroprotective effect to prevent contrast-induced acute kidney injury (CI-AKI) in patients with heart failure (HF) undergoing iodinated contrast medium (ICM) invasive procedures. (2) Methods: The population was stratified into SGLT2-i users and SGLT2-i non-users according to the chronic treatment with gliflozins. The primary endpoint was CI-AKI incidence during hospitalization. Secondary endpoints were all-cause mortality and the need for continuous renal replacement therapy (CRRT). (3) Results: In total, 86 patients on SGLT2-i and 179 patients not on SGLT2-i were enrolled. The incidence of CI-AKI in the gliflozin group was lower than in the non-user group (9.3 vs. 27.3%, p < 0.001), and these results were confirmed after propensity matching analysis. Multivariable logistic regression showed that only SGLT2-i treatment was an independent preventive factor for CI-AKI (OR: 0.41, 95% CI: 0.16-0.90, p = 0.045). The need for CRRT was reported only in five patients in the non-SGLT2-i-user group compared to zero patients in the gliflozin group (p = 0.05). (4) Conclusions: SGLT2-i therapy was associated with a lower risk of CI-AKI in patients with HF undergoing ICM invasive procedures.

Targeted Metabolomic Profiling of Dapagliflozin in Heart Failure With Preserved Ejection Fraction: The PRESERVED-HF Trial

BackgroundAlthough sodium glucose co-transporter 2 inhibitors (SGLT2is) improve heart failure (HF)-related symptoms and outcomes in HF with preserved ejection fraction (HFpEF), underlying mechanisms remain unclear. In HF with reduced EF, dapagliflozin altered ketone and fatty acid metabolites vs placebo; however, metabolite signatures of SGLT2is have not been well elucidated in HFpEF. ObjectivesThe goal of this study was to assess whether SGLT2i treatment altered systemic metabolic pathways and their relationship to outcomes in HFpEF. MethodsTargeted profiling of 64 metabolites was performed from 293 participants in PRESERVED-HF (Dapagliflozin in PRESERVED Ejection Fraction Heart Failure), a 12-week, placebo-controlled trial of dapagliflozin. Linear regression assessed changes in metabolite factors defined by principal components analysis (PCA) with dapagliflozin vs placebo. The relationship between changes in metabolite factors with changes in study endpoints was also assessed. ResultsThe mean age was 70 ± 11 years, 58% were female, and 29% were Black. There were no significant differences in 12 PCA-derived metabolite factors between treatment arms, including metabolites reflecting ketone, fatty acid, or branched-chain amino acid (BCAA) pathways. Combining treatment arms, changes in BCAAs and branched-chain ketoacids were negatively associated with changes in N-terminal pro–B-type natriuretic peptide; changes in medium-/long-chain acylcarnitines were positively associated with changes in N-terminal pro–B-type natriuretic peptide and negatively associated with changes in 6-minute walk test distance; and changes in ketones were negatively associated with changes in weight, without treatment interaction. ConclusionsLeveraging targeted metabolomics in a placebo-controlled SGLT2i trial of HFpEF, dapagliflozin did not alter systemic metabolic as reflected by circulating metabolites, in contrast with reported effects in HF with reduced ejection fraction. Metabolite biomarkers reflecting BCAA, ketone, and fatty acid metabolism were associated with markers of disease severity, suggesting a role for potential novel treatment targets. (Dapagliflozin in PRESERVED Ejection Fraction Heart Failure [PRESERVED-HF]; NCT03030235)

Dapagliflozin prevents ERK activation and SGLT2-dependent endoglin upregulation in a mechanically provoked cardiac injury model.

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are rapidly gaining ground in the treatment of heart failure (HF) with reduced ejection fraction (HFrEF) and acute myocardial infarction (AMI) by an unknown mechanism. Upregulation of Na+/H+ exchanger 1 (NHE1), SGLT1, and Ca2+/calmodulin-dependent protein kinase II (CaMKII) in the diseased hearts was found to be attenuated by prolonged SGLT2i treatment. Unfortunately, dapagliflozin is not well understood as to how Na+/Ca2+ homeostasis is affected in cardiomyocytes. In this study, we aimed to investigate whether mechanical stretch in cardiomyocytes upregulate SGLT2, resulted to loss of Na+/Ca2+ homeostasis via ERK and eNOS signaling. AMI (+) and AMI (-) serum levels were estimated using ELISA assays of TGFβ-1 or endoglin (CD105). Human cardiomyocyte cell line AC16 was subjected to different stresses: 5% mild and 25% aggressive, at 1 Hz for 24 h. Immunofluorescence assays were used to estimate troponin I, CD105, SGLT1/2, eNOSS633, and ERK1/2T202/Y204 levels was performed for 5% (mild), and 25% elongation for 24 h. AMI (+) serum showed increased TGFβ1 and CD105 compared to AMI (-) patients. In consistent, troponin I, CD105, SGLT1/2, eNOSS633 and ERK1/2T202/Y204 were upregulated after 25% of 24 h cyclic stretch. Dapagliflozin addition caused SGLT2 inhibition, which significantly decreased troponin I, CD105, SGLT1/2, eNOSS633, and ERK1/2T202/Y204 under 25% cyclic stretching. In summary, SGLT2 may have sensed mechanical stretch in a way similar to cardiac overloading as invivo. By blocking SGLT2 in stretched cardiomyocytes, the AMI biomarkers (CD105, troponin I and P-ERK) were decreased, potentially to rescue eNOS production to maintain normal cellular function. This discovery of CD105 and SGLT2 increase in mechanically stretched cardiomyocytes suggests that SGLT2 may conceive a novel role in direct or indirect sensing of mechanical stretch, prompting the possibility of an invitro cardiac overloaded cell model, an alternative to animal heart model.

Body mass index and cardiorenal outcomes in the EMPEROR-Preserved trial: Principal findings and meta-analysis with the DELIVER trial.

Both low and high body mass index (BMI) are associated with poor heart failure outcomes. Whether BMI modifies benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in heart failure with preserved ejection fraction (HFpEF) requires further investigation. Using EMPEROR-Preserved data, the effects of empagliflozin versus placebo on the risks for the primary outcome (hospitalization for heart failure [HHF] or cardiovascular [CV] death), change in estimated glomerular filtration rate (eGFR) slopes, change in Kansas City Cardiomyopathy Questionnaire clinical summary score (KCCQ-CSS), and secondary outcomes across baseline BMI categories (<25 kg/m2, 25 to <30 kg/m2, 30 to <35 kg/m2, 35 to <40 kg/m2 and ≥40 kg/m2) were examined, and a meta-analysis conducted with DELIVER. Forty-five percent had a BMI of ≥30 kg/m2. For the primary outcome, there was a consistent treatment effect of empagliflozin versus placebo across the BMI categories with no formal interaction (p trend = 0.19) by BMI categories. There was also no difference in the effects on secondary outcomes including total HHF (p trend = 0.19), CV death (p trend = 0.20), or eGFR slope with slower declines with empagliflozin regardless of BMI (range 1.12-1.71 ml/min/1.73 m2 relative to placebo, p trend = 0.85 for interaction), though there was no overall impact on the composite renal endpoint. The difference in weight change between empagliflozin and placebo was -0.59, -1.48, -1.54, -0.87, and - 2.67 kg in the lowest to highest BMI categories (p trend = 0.016 for interaction). A meta-analysis of data from EMPEROR-Preserved and DELIVER showed a consistent effect of SGLT2i versus placebo across BMI categories for the outcome of HHF or CV death. There was a trend toward greater absolute KCCQ-CSS benefit at 32 weeks with empagliflozin at higher BMIs (p = 0.08). Empagliflozin treatment resulted in broadly consistent cardiac effects across the range of BMI in patients with HFpEF. SGLT2i treatment yields benefit in patients with HFpEF regardless of baseline BMI.