Cardiorenal Protection With the Newer Antidiabetic Agents in Patients With Diabetes and Chronic Kidney Disease: A Scientific Statement From the American Heart Association

Abstract

Chronic kidney disease (CKD) with type 2 diabetes (T2D) is a major public health problem, resulting in significant cardiovascular and kidney adverse outcomes worldwide. Despite the widespread use of standard-of-care therapies for CKD with T2D over the past few decades, rates of progression to end-stage kidney disease remain high with no beneficial impact on its accompanying burden of cardiovascular disease. The advent of the newer classes of antihyperglycemic agents, including SGLT2 (sodium glucose cotransporter 2) inhibitors and GLP-1 (glucagon-like peptide-1) receptor agonists, has changed the landscape of therapeutic options for patients with CKD with T2D, with demonstration of significant reductions in cardiovascular adverse events and progression to end-stage kidney disease. Several potential mechanisms exist through which these beneficial effects are achieved in both drug classes, which may be independent of their antihyperglycemic effects. This scientific statement summarizes the current literature on the cardiorenal protective effects with SGLT2 inhibitors and GLP-1 receptor agonists in patients with CKD and T2D. It reviews potential mechanistic pathways that may drive these benefits and summarizes the literature on adverse effects in patients with CKD and T2D at risk for or with established cardiovascular disease. Last, it provides practical guidance on a proposed collaborative care model bridging cardiologists, nephrologists, endocrinologists, and primary care physicians to facilitate the prompt and appropriate integration of these therapeutic classes in the management of patients with T2D and CKD.

Newer drug treatments for type 2 diabetes

“…Whether sufficiently robust evidence exists for low risk patients is debatable. Third, the guidance does not consider selection of individual drugs within each of the two therapeutic classes, although evidence suggests possible variation in benefits and risks 517…”

Effect of combined renin angiotensin aldosterone inhibitors and diuretic treatment among patients hospitalized with SARS-CoV-2 Infection COVID-19

“…[20] This principle appears to extend to patients hospitalized with COVID-19 at high risk for acute cardiorenal syndromes. [21,22] Recently, the BRACE CORONA trial showed no association between RAASi continuation and the primary outcome of death following hospital discharge for patients with COVID-19. [17] Further, a separate study demonstrated that discontinuation of RAASi therapy for patients hospitalized with COVID-19 was associated with increased risk of mortality following discharge.…”

Modern Approaches to Non-Insulin Therapy of Patients with Type 2 Diabetes Mellitus

“…В настоящее время препараты группы иНГЛТ-2 рекомендуют пациентам с СКФ от 30 мл/мин 1,73 м 2 и выше (табл. 1) [23][24][25][26][27].…”

“…В исследовании REWIND дулаглутид снижал частоту сердечно-сосудистых событий на 12%, лираглутид в исследовании LEADER уменьшал риск ССЗ на 13%, семаглутид (в инъекциях) в исследовании SUSTAIN-6 -на 26%, семаглутид (пероральная форма) в PIONER-6 -на 21% (табл. 2) [23].…”

“…Более того, арГПП-1 (лираглутид, дулаглутид, семаглутид) замедляли прогрессирование альбуминурии. Таким образом, вновь выявленным пациентам с СД 2 типа и ССЗ, а также больным с очень высоким риском ССЗ рекомендуется препарат из группы иНГЛТ-2 или арГПП-1 или его добавление к терапии метформином [23].…”