The edition · Nephrology
Semaglutide in diabetic CKD: no new safety concerns down to eGFR below 30
A prespecified FLOW analysis found fewer serious adverse events than placebo at every level of kidney function. Plus statins after a cardiovascular event in dialysis, hepcidin as a double-edged marker in CKD, and the expected eGFR dip on SGLT2 inhibitors.
The edition in brief
A prespecified secondary analysis of the FLOW trial (3,533 people with type 2 diabetes and CKD) reported safety by baseline eGFR. Serious adverse events were less frequent with semaglutide than placebo in every subgroup, including eGFR below 30 (56.4% vs 60.4%). Discontinuation for any adverse event rose as kidney function fell, equally in both arms (about 19% below eGFR 30), while discontinuation for gastrointestinal effects was higher with semaglutide (4.5% vs 1.1%). A French registry study of 5,534 dialysis patients after an atherosclerotic event, analysed as a target-trial emulation, associated statin initiation with lower mortality (maximum absolute difference 6.2% at four years; mean survival gain 135 days at ten years) and no excess rhabdomyolysis or hepatitis admissions. In 3,826 CRIC participants, high plasma hepcidin was associated with more kidney progression and atherosclerotic events, and low hepcidin with higher mortality. The pearl covers the early eGFR dip after starting an SGLT2 inhibitor.
On dialysis after a heart attack or stroke: starting a statin was linked to longer survival
Guidance on statins in dialysis is unchanged, but after an atherosclerotic event a statin is worth discussing; this observational evidence links it to modestly longer survival without excess toxicity.
Hepcidin in CKD: high levels tracked kidney decline, low levels tracked death
Keep using ferritin and transferrin saturation to guide iron in CKD; hepcidin is a research marker linked to risk at both extremes.
The eGFR dip after starting an SGLT2 inhibitor is expected
Expect and explain a small early eGFR dip after starting an SGLT2 inhibitor, and continue the drug unless the fall is large or the patient is volume depleted.
Semaglutide in diabetic kidney disease: safety held even below eGFR 30
Consider semaglutide for type 2 diabetes with CKD across the eGFR range studied, including below 30, with slow titration and attention to gastrointestinal effects.
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