The edition · Nephrology
Four doses of dapagliflozin halved acute kidney injury after cardiac surgery
A Dutch randomised trial gave 784 elective cardiac surgery patients dapagliflozin 10 mg from the day before surgery through the second postoperative day. Acute kidney injury fell from 52% to 28%. Plus SGLT2 inhibitors disappoint in polycystic kidney disease, and KDIGO places the new IgA nephropathy drugs.
The edition in brief
No drug has previously been shown to prevent acute kidney injury after cardiac surgery. This multicentre Dutch trial randomised 784 adults undergoing elective cardiac surgery to dapagliflozin 10 mg or placebo, starting the day before surgery and continuing through the second postoperative day — four doses in total. Acute kidney injury by KDIGO criteria over seven days occurred in 28% on dapagliflozin and 52% on placebo (relative risk 0.54, 95% CI 0.45 to 0.65, p<0.001). Atrial fibrillation was identical at 45% in both arms, and reoperation was 11% versus 10%. Median age was 68 and 97% of participants were White. An individual participant data meta-analysis of CANVAS and CREDENCE, restricted to 7,990 participants aged 50 or over, found canagliflozin reduced end-stage kidney disease with a pooled hazard ratio of 0.535 (95% CI 0.392 to 0.729), a number needed to treat of 27.5 over three years in CREDENCE. Cardiovascular mortality favoured canagliflozin but did not reach significance (pooled hazard ratio 0.841, 95% CI 0.669 to 1.058). A meta-analysis of six studies and 451 patients found insufficient evidence that SGLT2 inhibitors benefit kidney outcomes in autosomal dominant polycystic kidney disease, with no effect on total kidney volume. KDIGO has issued a commentary placing three newly approved IgA nephropathy therapies within the treatment strategy, and the TRIDENT cohort proposes a new histological class in diabetic nephropathy defined by visceral epithelial hyperplasia.
Dapagliflozin around cardiac surgery halved postoperative acute kidney injury
Four perioperative doses of dapagliflozin around elective cardiac surgery cut KDIGO-defined acute kidney injury from 52% to 28%, with no excess atrial fibrillation or reoperation.
Canagliflozin cut end-stage kidney disease by nearly half in adults over 50
In adults over 50 with diabetic kidney disease, canagliflozin reduced end-stage kidney disease by 46.5%, needing about 28 patients treated for three years to prevent one case.
KDIGO places three newly approved IgA nephropathy drugs; no new drug action in today's sweep
No new drug regulatory action today; in IgA nephropathy, optimise supportive care including an SGLT2 inhibitor before adding any of the newly approved targeted agents, whose approvals rest on proteinuria rather than kidney function.
SGLT2 inhibitors have not been shown to help in polycystic kidney disease
There is no evidence that SGLT2 inhibitors slow autosomal dominant polycystic kidney disease, including no effect on total kidney volume — prescribe them only for a separate indication.
TRIDENT: a new histological class identifies the fastest progressors in diabetic nephropathy
Visceral epithelial hyperplasia on a diabetic nephropathy biopsy identifies the fastest progressors to kidney failure — ask your pathologist to report it explicitly.
The SGLT2 inhibitor sick-day rule nobody writes down
Write the SGLT2 inhibitor sick-day rule down and name who restarts it after surgery — and check ketones rather than glucose in any unwell patient taking one.
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