Atrasentan and renal events in patients with type 2 diabetes and chronic kidney disease (SONAR): a double-blind, randomised, placebo-controlled trial

Background: Short-term treatment for people with type 2 diabetes using a low dose of the selective endothelin A receptor antagonist atrasentan reduces albuminuria without causing significant sodium retention. We report the long-term effects of treatment with atrasentan on major renal outcomes. Methods: We did this double-blind, randomised, placebo-controlled trial at 689 sites in 41 countries. We enrolled adults aged 18–85 years with type 2 diabetes, estimated glomerular filtration rate (eGFR)25–75 mL/min per 1·73 m 2 of body surface area, and a urine albumin-to-creatinine ratio (UACR)of 300–5000 mg/g who had received maximum labelled or tolerated renin–angiotensin system inhibition for at least 4 weeks. Participants were given atrasentan 0·75 mg orally daily during an enrichment period before random group assignment. Those with a UACR decrease of at least 30% with no substantial fluid retention during the enrichment period (responders)were included in the double-blind treatment period. Responders were randomly assigned to receive either atrasentan 0·75 mg orally daily or placebo. All patients and investigators were masked to treatment assignment. The primary endpoint was a composite of doubling of serum creatinine (sustained for ≥30 days)or end-stage kidney disease (eGFR <15 mL/min per 1·73 m 2 sustained for ≥90 days, chronic dialysis for ≥90 days, kidney transplantation, or death from kidney failure)in the intention-to-treat population of all responders. Safety was assessed in all patients who received at least one dose of their assigned study treatment. The study is registered with ClinicalTrials.gov, number NCT01858532. Findings: Between May 17, 2013, and July 13, 2017, 11 087 patients were screened; 5117 entered the enrichment period, and 4711 completed the enrichment period. Of these, 2648 patients were responders and were randomly assigned to the atrasentan group (n=1325)or placebo group (n=1323). Median follow-up was 2·2 years (IQR 1·4–2·9). 79 (6·0%)of 1325 patients in the atrasentan group and 105 (7·9%)of 1323 in the placebo group had a primary composite renal endpoint event (hazard ratio [HR]0·65 [95% CI 0·49–0·88]; p=0·0047). Fluid retention and anaemia adverse events, which have been previously attributed to endothelin receptor antagonists, were more frequent in the atrasentan group than in the placebo group. Hospital admission for heart failure occurred in 47 (3·5%)of 1325 patients in the atrasentan group and 34 (2·6%)of 1323 patients in the placebo group (HR 1·33 [95% CI 0·85–2·07]; p=0·208). 58 (4·4%)patients in the atrasentan group and 52 (3·9%)in the placebo group died (HR 1·09 [95% CI 0·75–1·59]; p=0·65). Interpretation: Atrasentan reduced the risk of renal events in patients with diabetes and chronic kidney disease who were selected to optimise efficacy and safety. These data support a potential role for selective endothelin receptor antagonists in protecting renal function in patients with type 2 diabetes at high risk of developing end-stage kidney disease. Funding: AbbVie

Subacute Thyroiditis&mdash;Still a Diagnostic Challenge: Data from an Observational Study

Background: Subacute thyroiditis (SAT) is a relatively common cause of thyroid disease. However, only a few studies evaluating SAT have been published in recent years with varying diagnostic criteria. We evaluate the clinical presentation and long-term outcome of isotope scan-confirmed SAT. Methods: A retrospective study of 38 patients with isotope scan-confirmed SAT was performed at a single isotope department. All patients were contacted for long-term follow-up. Results: The female/male ratio was 1.4:1, and mean age was 47 &plusmn; 14 years and 62 &plusmn; 12 years in women and men, respectively (p = 0.002). Almost half of the cases (42%) occurred during the summer. The most common symptoms were neck pain (74%) and weakness (61%). Palpitations, weight loss, heat intolerance, and sweating appeared in 50%, 42%, 21%, and 21%, respectively. Only half of the patients reported fever. TSH level was low in all patients, and mean FT4 and FT3 level were about twice the upper limit of normal range. Elevated CRP and ESR occurred in the majority (88%) of patients. The mean time period between the first clinic visit and performing thyroid function tests was 8 &plusmn; 7 days. One-third of the patients initially received a diagnosis of upper respiratory tract infection (URI). NSAIDs and steroids were prescribed to 47% and 8% of patients, respectively. Long-term follow-up of 33.5 months (range 9&ndash;52) revealed that 25% remained with subclinical or overt hypothyroidism. Conclusions: These data demonstrate that although SAT is a common entity, there is still a significant delay in diagnosis, and in a third of our patients, the initial diagnosis was URI, with 25% developing long-term hypothyroidism

Protein tyrosine phosphatase alpha inhibits hypothalamic leptin receptor signaling and regulates body weight in vivo

Understanding how body weight is regulated at the molecular level is essential for treating obesity. We show that female mice genetically lacking protein tyrosine phosphatase (PTP) receptor type α (PTPRA) exhibit reduced weight and adiposity and increased energy expenditure, and are more resistant to diet-induced obesity than matched wild-type control mice. These mice also exhibit reduced levels of circulating leptin and are leptin hypersensitive, suggesting that PTPRA inhibits leptin signaling in the hypothalamus. Male and female PTPRA-deficient mice fed a high-fat diet were leaner and displayed increased metabolic rates and lower circulating leptin levels, indicating that the effects of loss of PTPRA persist in the obese state. Molecularly, PTPRA down-regulates leptin receptor signaling by dephosphorylating the receptor-associated kinase JAK2, with which the phosphatase associates constitutively. In contrast to the closely related tyrosine phosphatase ε, leptin induces only weak phosphorylation of PTPRA at its C-terminal regulatory site Y789, and this does not affect the activity of PTPRA toward JAK2. PTPRA is therefore an inhibitor of hypothalamic leptin signaling in vivo and may prevent premature activation of leptin signaling, as well as return signaling to baseline after exposure to leptin.-Cohen-Sharir, Y., Kuperman, Y., Apelblat, D., den Hertog, J., Spiegel, I., Knobler, H., Elson, A. Protein tyrosine phosphatase alpha inhibits hypothalamic leptin receptor signaling and regulates body weight in vivo

Following the COVID-19 Experience, Many Patients with Type 1 Diabetes Wish to Use Telemedicine in a Hybrid Format

Background: The COVID-19 pandemic has brought to light both challenges and unique opportunities regarding type 1 diabetes (T1D) management, including the usage of telemedicine platforms. Methods: This study was conducted in a tertiary hospital diabetes clinic. All consecutive T1D patients during March and June 2021 were asked to fill out a structured anonymous questionnaire that aimed to determine their preference regarding continuous use of a virtual platform. Results: In total, 126 T1D patients answered the questionnaire, of whom 51% were under the age of 40, half were men, half used insulin pumps, and 69% used continuous glucose monitoring. During the pandemic, the exposure of patients to virtual visits has grown about twofold, from 29% to 53%. Of the respondents, 49% expressed an interest in future usage of a virtual platform, but most of them preferred use in a hybrid manner. We found an association between preference to use telemedicine in the future and younger age, previous virtual platform experience, and confidence in being able to download data. Conclusions: Our data demonstrate that the COVID-19 experience has led to a growing interest of T1D patients in using the hybrid format of telemedicine. However, we still need to better understand who will benefit most from this platform and assess its cost-effectiveness and organization

Prebiotic Treatment in Patients with Nonalcoholic Fatty Liver Disease (NAFLD)—A Randomized Pilot Trial

Several studies show that gut microbiotas in patients with nonalcoholic fatty liver disease (NAFLD) differ from those in a healthy population, suggesting that this alteration plays a role in NAFLD pathogenesis. We investigated whether prebiotic administration affects liver fat content and/or liver-related and metabolic parameters. Patients with NAFLD and metabolic syndrome (age: 50 ± 11; 79% men) were randomized to receive either 16 g/day of prebiotic (ITFs—inulin-type fructans) (n = 8) or placebo (maltodextrin) (n = 11) for 12 weeks. Patients were instructed to maintain a stable weight throughout the study. Liver fat content (measured by H1MRS), fecal microbiota, and metabolic, inflammatory, and liver parameters were determined before and after intervention. Fecal samples from patients who received the prebiotic had an increased content of Bifidobacterium (p = 0.025), which was not observed with the placebo. However, the baseline and end-of-study liver fat contents did not change significantly in the prebiotic and placebo groups, neither did the liver function tests’ metabolic and inflammatory mediators, including fibroblast growth factor-19 and lipopolysaccharide-binding protein. Body weight remained stable in both groups. These findings suggest that prebiotic treatment without weight reduction is insufficient to improve NAFLD

Tyrosine Phosphatase Epsilon Is a Positive Regulator of Osteoclast Function in Vitro and In Vivo

Protein tyrosine phosphorylation is a major regulator of bone metabolism. Tyrosine phosphatases participate in regulating phosphorylation, but roles of specific phosphatases in bone metabolism are largely unknown. We demonstrate that young (<12 weeks) female mice lacking tyrosine phosphatase epsilon (PTPε) exhibit increased trabecular bone mass due to cell-specific defects in osteoclast function. These defects are manifested in vivo as reduced association of osteoclasts with bone and as reduced serum concentration of C-terminal collagen telopeptides, specific products of osteoclast-mediated bone degradation. Osteoclast-like cells are generated readily from PTPε-deficient bone-marrow precursors. However, cultures of these cells contain few mature, polarized cells and perform poorly in bone resorption assays in vitro. Podosomes, structures by which osteoclasts adhere to matrix, are disorganized and tend to form large clusters in these cells, suggesting that lack of PTPε adversely affects podosomal arrangement in the final stages of osteoclast polarization. The gender and age specificities of the bone phenotype suggest that it is modulated by hormonal status, despite normal serum levels of estrogen and progesterone in affected mice. Stimulation of bone resorption by RANKL and, surprisingly, Src activity and Pyk2 phosphorylation are normal in PTPε-deficient osteoclasts, indicating that loss of PTPε does not cause widespread disruption of these signaling pathways. These results establish PTPε as a phosphatase required for optimal structure, subcellular organization, and function of osteoclasts in vivo and in vitro