Estimated Lifetime Cardiovascular, Kidney, and Mortality Benefits of Combination Treatment With SGLT2 Inhibitors, GLP-1 Receptor Agonists, and Nonsteroidal MRA Compared With Conventional Care in Patients With Type 2 Diabetes and Albuminuria

Circulation, Journal Year: 2023, Volume and Issue: 149(6), P. 450 - 462

Published: Nov. 12, 2023

BACKGROUND: Sodium glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1 RA), and the nonsteroidal mineralocorticoid antagonist (ns-MRA) finerenone all individually reduce cardiovascular, kidney, mortality outcomes in patients with type diabetes albuminuria. However, lifetime benefits of combination therapy these medicines are not known. METHODS: We used data from SGLT2i trials (CANVAS [Canagliflozin Cardiovascular Assessment] CREDENCE Renal Events Diabetes Established Nephropathy Clinical Evaluation]), ns-MRA (FIDELIO-DKD [Finerenone Reducing Kidney Failure Disease Progression Diabetic Disease] FIGARO-DKD [Efficacy Safety Finerenone Subjects With Type Mellitus Diagnosis Disease]), 8 GLP-1 RA to estimate relative effects versus conventional care (renin-angiotensin system blockade traditional risk factor control) on outcomes. Using actuarial methods, we then estimated absolute reductions SGLT2i, RA, at least moderately increased albuminuria (urinary albumin:creatinine ratio ≥30 mg/g) by applying treatment participants receiving CANVAS CREDENCE. RESULTS: Compared care, was associated a hazard 0.65 (95% CI, 0.55–0.76) for major adverse cardiovascular events (nonfatal myocardial infarction, nonfatal stroke, or death). The corresponding reduction over 3 years 4.4% 3.0–5.7), number needed treat 23 18–33). For 50-year-old patient commencing therapy, event–free survival 21.1 compared 17.9 (3.2 gained [95% 2.1–4.3]). There were also projected gains free hospitalized heart failure 2.4–4.0]), chronic kidney disease progression (5.5 4.0–6.7]), death (2.2 1.2–3.0]), all-cause (2.4 1.4–3.4]). Attenuated but clinically relevant event-free observed analyses assuming 50% additive including 1.1–3.5]), (4.5 2.8–5.9]), (1.8 0.7–2.8]). CONCLUSIONS: In albuminuria, has potential afford overall survival.

Language: Английский

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Estimated Prevalence and Testing for Albuminuria in US Adults at Risk for Chronic Kidney Disease

JAMA Network Open, Journal Year: 2023, Volume and Issue: 6(7), P. e2326230 - e2326230

Published: July 27, 2023

Importance Albuminuria testing is crucial for guiding evidence-based treatments to mitigate chronic kidney disease (CKD) progression and cardiovascular morbidity, but it widely underutilized among persons with or at risk CKD. Objective To estimate the extent of albuminuria underdetection from lack evaluate its association CKD treatment in a large US cohort patients hypertension diabetes. Design, Setting, Participants This study examined adults diabetes, using data 2007 2018 National Health Nutrition Examination Surveys (NHANES) Optum deidentified electronic health record (EHR) set diverse care organizations. Analyses were conducted October 31, 2022, May 19, 2023. Main Outcomes Measures Using NHANES as nationally representative sample, logistic regression model was developed (urine albumin-creatinine ratio ≥30 mg/g). then applied active outpatients EHR January 1, 2017, December 2018. The prevalence those without during this period estimated. A multivariable used examine associations between having therapies within subsequent year (prescription angiotensin-converting enzyme inhibitor [ACEi] angiotensin II receptor blocker [ARB], prescription sodium-glucose cotransporter 2 [SGLT2i], blood pressure control less than 130/80 mm Hg 140/90 on latest outpatient measure). Results total population included 192 108 (mean [SD] age, 60.3 [15.1] years; 185 589 [96.6%] hypertension; 50 507 [26.2%] diabetes; mean eGFR, 84 [21] mL/min/1.73 m ). There 33 629 (17.5%) who had testing; whom 11 525 (34.3%) albuminuria. Among 158 479 untested, estimated rate 13.4% (n = 21 231). Thus, only 35.2% (11 32 756) projected been tested. associated higher adjusted odds receiving ACEi ARB (OR, 2.39 [95% CI, 2.32-2.46]), SGLT2i 8.22 7.56-8.94]), controlled 1.20 1.16-1.23]). Conclusions Relevance In that approximately two-thirds undetected due testing. These results suggest improving detection represents substantial opportunity optimize delivery reducing complications.

Language: Английский

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Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure

Journal of the American College of Cardiology, Journal Year: 2024, Volume and Issue: 83(14), P. 1295 - 1306

Published: April 1, 2024

Language: Английский

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Efficacy and safety of SGLT2 inhibitors with and without glucagon-like peptide 1 receptor agonists: a SMART-C collaborative meta-analysis of randomised controlled trials

The Lancet Diabetes & Endocrinology, Journal Year: 2024, Volume and Issue: 12(8), P. 545 - 557

Published: July 8, 2024

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International consensus on post-transplantation diabetes mellitus

Nephrology Dialysis Transplantation, Journal Year: 2024, Volume and Issue: 39(3), P. 531 - 549

Published: Jan. 3, 2024

ABSTRACT Post-transplantation diabetes mellitus (PTDM) remains a leading complication after solid organ transplantation. Previous international PTDM consensus meetings in 2003 and 2013 provided standardized frameworks to reduce heterogeneity diagnosis, risk stratification management. However, the last decade has seen significant advancements our knowledge complemented by rapidly changing treatment algorithms for management of general population. In view these developments, ensure reduced variation clinical practice, 3rd Consensus Meeting was planned held from 6–8 May 2022 Vienna, Austria involving global delegates with expertise update previous reports. This includes opinion statements concerning optimal diagnostic tools, recognition prediabetes (impaired fasting glucose and/or impaired tolerance), new mechanistic insights, immunosuppression modification, evidence-based strategies prevent PTDM, hierarchy incorporating novel glucose-lowering agents suggestions future direction research address unmet needs. Due paucity good quality evidence, meeting participants agreed that making GRADE (Grading Recommendations, Assessment, Development, Evaluations) recommendations would be flawed. Although kidney-allograft centric, we suggest can appraised transplantation community implementation across different transplant cohorts. Acknowledging published literature, this report reflects expert opinion. Attaining evidence is desirable establishment optimized care any recipient at of, or who develops, as strive improve long-term outcomes.

Language: Английский

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Prescription of guideline‐directed medical therapies in patients with diabetes and chronic kidney disease from the CURE‐CKD Registry, 2019‐2020

Diabetes Obesity and Metabolism, Journal Year: 2023, Volume and Issue: 25(10), P. 2970 - 2979

Published: July 3, 2023

Abstract Aim Guideline‐directed medical therapy (GDMT) is designed to improve clinical outcomes. The study aim was assess GDMT prescribing rates and prescribing‐persistence predictors in patients with diabetes chronic kidney disease (CKD) from the Center for Kidney Disease Research, Education, Hope Registry. Materials Methods Data were obtained adults ≥18 years old CKD between 1 January 2019 31 December 2020 (N = 39 158). Baseline persistent (≥90 days) prescriptions GDMT, including angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), sodium‐glucose cotransporter‐2 (SGLT2) inhibitor glucagon‐like peptide (GLP‐1) agonist assessed. Results population age (mean ± SD) 70 14 years, 49.6% (n 19 415) women. estimated glomerular filtration rate (2021 CKD‐Epidemiology Collaboration creatinine equation) 57.5 23.0 ml/min/1.73 m 2 urine albumin/creatinine mg/g (31.7‐158.2; median, interquartile range). ≥90‐day rates, respectively, 70.7% 40.4% ACE inhibitor/ARB, 6.0% 5.0% SGLT2 inhibitors, 6.8% 6.3% GLP‐1 (all p < .001). Patients lacking primary commercial health insurance coverage less likely be prescribed an inhibitor/ARB [odds ratio (OR) 0.89; 95% confidence interval (CI) 0.84‐0.95; .001], (OR 0.72; CI 0.64‐0.81; .001) or 0.80‐0.98; .02). lower at Providence than UCLA Health. Conclusions Prescribing suboptimal waned quickly CKD. Type of system associated prescribing.

Language: Английский

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

EClinicalMedicine, Journal Year: 2024, Volume and Issue: 68, P. 102426 - 102426

Published: Jan. 21, 2024

The cardiovascular and kidney benefits of sodium-glucose co-transporter-2 (SGLT2) inhibitors in people with chronic disease (CKD) are well established. implementation updated SGLT2 inhibitor guidelines prescribing the real-world CKD population remains largely unknown.

Language: Английский

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Cardiovascular-Kidney-Metabolic Health Syndrome

Journal of the American Society of Nephrology, Journal Year: 2024, Volume and Issue: 35(5), P. 649 - 652

Published: Feb. 6, 2024

Overview of the American Heart Association's Cardiovascular-Kidney-Metabolic Syndrome Obesity, diabetes, and CKD are highly prevalent, commonly co-occur, substantially increase cardiovascular disease morbidity mortality. The mechanisms these four states also closely intertwined, with multidirectional relationships, shared risk factors, common therapeutic targets. Given complex interactions among diseases, Association (AHA) recently proposed a new integrated health disorder, cardiovascular-kidney-metabolic (CKM) syndrome, defined as disorder attributable to connections obesity, CKD, disease.1,2 CKM framework aims move beyond individual factor management, proposing systemic staging system for those at for, with, existing (Figure 1). This is designed better reflect pathophysiology, spectrum risk, opportunities prevention care optimization within syndrome. Stage 0 includes individuals who not overweight/obese do have metabolic factors (e.g., hypertension, hypertriglyceridemia), or subclinical/clinical disease. 1 excess and/or dysfunctional adiposity, manifested by high body mass index, waist circumference, fasting blood sugar. Individuals in this stage other CKD. 2 (hypertriglyceridemia, diabetes) 3 subclinical atherosclerotic (atherosclerosis coronary artery calcium) heart failure (elevated cardiac biomarkers echocardiographic parameters) excess/dysfunctional Risk equivalents include G4 G5 Finally, 4 clinical (coronary disease, failure, stroke, peripheral atrial fibrillation) CKD.1,2Figure 1: Stages Reprinted from ref. permission. AFib, fibrillation; ASCVD, disease; CHD, CKM, cardiovascular-kidney-metabolic; CVD, HF, failure; KDIGO, Kidney Disease Improving Global Outcomes; PAD, arterial disease.Nephrologists substantial role caring across stages. What does mean nephrology kidney patients? Earlier Detection Cardiovascular including often silent undetected until clinically apparent present. emphasizes early detection recommends assessment both eGFR urine albumin-creatinine ratio at-risk individuals, hypertriglyceridemia>135 mg/dl, hypertension (stage higher), Notably, calls albuminuria 1, obesity adiposity without We hope that AHA raises awareness promotes screening primary subspecialty clinicians seeing patients course measurement urinary albumin-to-creatinine (UACR) has remained dismally low despite previous guideline recommendations.3 accelerates implementation more broadly United States, expansive recommendation currently being considered US Preventative Services Task Force. using UACR even moderate may delay prevent progression life-years quality life, reduce costs.4,5 Lifespan just affecting older adults. As incidence diseases increases younger children, greater guidance needed on how when screen complications such proposes life (age <21 years) hypertriglyceridemia, hypertension. could impact lifetime survival life.6 Focus Severity, Including Patients Treated Dialysis Until now, outside guidelines, largely been treated single entity, less attention dialysis. With framework, Outcomes resulting designation least CKM. In dialysis separated because unique approaches management treatment (in context lack data guide decisions). Consideration Function Guideline-Directed Medical Therapy Guideline-directed medical therapy therapies, renin-angiotensin-aldosterone inhibitors, mineralocorticoid receptor antagonists, sodium-glucose cotransporter-2 glucagon-like peptide-1 agonists, remain underutilized strong evidence they improve outcomes slow CKD.7 There barriers initiation medications part due social determinants [SDOH]), most likely benefit receive therapies.8 addition, some therapies short-term hemodynamic effects function higher rates adverse which can lead premature discontinuation therapies. approach encourages continuation important current barrier extends nephrology. critical need trials evaluate strategies uptake guideline-directed pace titration. New Score That Includes Previous scores typically included prediction variables. Predicting CVD EVENTs (PREVENT) model traditional (age, total cholesterol, non-HDL HDL systolic BP, smoking, medications, statins) predictors, additional models tailored high-risk inclusion available.9,10 If gets implemented into practice, would prompt earlier wider UACR. PREVENT predicts addition an whom comparable (or exceed) Furthermore, equation race variable, therefore aligning recent race-free equations. Social Determinants Health SDOHs prevalent strongly linked However, there significant gaps identifying our patients. score incorporate deprivation index. step forward recognizing importance biological factors; hopefully will systematic interventions. Patient Education Many people unaware their diagnosis; be symptoms ineffective communication education. help start conversations about treatment) professionals Interdisciplinary Care Models value-based interdisciplinary fragmentation inequitable access occur overlapping conditions. statement suggests team supported coordinator representation care, cardiology, nephrology, endocrinology, pharmacy, nursing, well navigators, workers, community workers. targeted referrals subspecialists activate expertise recommended higher-risk principles espoused here appropriate; however, marked shifts models, particularly States where payers seldom take multiyear perspectives, financial aspects widely. Next Steps: Putting Practice AHA's places center bringing often-overlooked public advance provides opportunity forge partnerships integrating factors. hopeful changes guidelines implement broader newer protective motivate propagation collaborative models. we research field, investigation etiologies disease-specific treatments; severity (including patients); trials.

Language: Английский

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Concordance With Screening and Treatment Guidelines for Chronic Kidney Disease in Type 2 Diabetes

JAMA Network Open, Journal Year: 2024, Volume and Issue: 7(6), P. e2418808 - e2418808

Published: June 26, 2024

Importance Chronic kidney disease (CKD) is an often-asymptomatic complication of type 2 diabetes (T2D) that requires annual screening to diagnose. Patient-level factors linked inadequate and treatment can inform implementation strategies facilitate guideline-recommended CKD care. Objective To identify risk for nonconcordance with in patients T2D. Design, Setting, Participants This retrospective cohort study was performed at 20 health care systems contributing data the US National Patient-Centered Clinical Research Network. evaluate concordance guidelines, adults outpatient clinician visit T2D diagnosis between January 1, 2015, December 31, 2020, without known were included. A separate analysis reviewed prescription angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) sodium-glucose cotransporter (SGLT2) (estimated glomerular filtration rate [eGFR] 30-90 mL/min/1.73 m urinary albumin-to-creatinine ratio [UACR] 200-5000 mg/g) October 2019, 2020. Data analyzed from July 8, 2022, through June 22, 2023. Exposures Demographics, lifestyle factors, comorbidities, medications, laboratory results. Main Outcomes Measures Screening required measurement creatinine levels UACR within 15 months index visit. Treatment reflected ACEIs ARBs SGLT2 12 before 6 following Results Concordance guidelines assessed 316 234 (median age, 59 [IQR, 50-67] years), whom 51.5% women; 21.7%, Black; 10.3%, Hispanic; 67.6%, White. Only 24.9% received screening, 56.5% 1 measurement, 18.6% neither. Hispanic ethnicity associated lack (relative [RR], 1.16 [95% CI, 1.14-1.18]). In contrast, heart failure, peripheral arterial disease, hypertension a lower nonconcordance. 4215 albuminuria, 3288 (78.0%) ACEI ARB; 194 (4.6%), inhibitor; 885 (21.0%), neither therapy. Peripheral eGFR treatment, while diuretic statin treatment. Conclusions Relevance this T2D, fewer than one-quarter recommended screening. 21.0% did not receive inhibitor ARB, despite compelling indications. may improve people

Language: Английский

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Estimating the population-level impacts of improved uptake of SGLT2 inhibitors in patients with chronic kidney disease: a cross-sectional observational study using routinely collected Australian primary care data

The Lancet Regional Health - Western Pacific, Journal Year: 2023, Volume and Issue: 43, P. 100988 - 100988

Published: Dec. 18, 2023

Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk of kidney failure and death in patients with chronic disease (CKD) but are underused. We evaluated number CKD Australia that would be eligible for treatment estimated cardiorenal events could averted improved uptake SGLT2 inhibitors.

Language: Английский

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