Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to 300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m 2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Taxonomy, phylogeny and identification of Botryosphaeriaceae associated with pome and stone fruit trees in South Africa and other regions of the world

Species of Botryosphaeria are well-recognized pathogens of pome and stone fruit trees. The taxonomy of these fungi, however, has been confused in the past. Recent taxonomic changes to the Botryosphaeriaceae further influence the literature pertaining to these fungi. This study reviews the taxonomic status of Botryosphaeriaceae associated with fruit tree diseases, identifies them in South Africa and elsewhere, and develops a reliable identification technique for them. Comparisons were made using DNA sequence data from the nuclear ITS rRNA operon and anamorph morphology. These analyses distinguished six clades amongst isolates associated with fruit tree diseases, corresponding to Neofusicoccum ribis (= B. ribis), N. parvum (= B. parva), N. australe (= B. australis), B. dothidea, Diplodia mutila (= B. stevensii) and ¿Botryosphaeria¿ obtusa (the genus Botryosphaeria is no longer available for the fungus known as B. obtusa, but a new name has not been proposed yet). Isolates from fruit trees in South Africa were grouped in the N. australe and ¿Botryosphaeria¿ obtusa clades. This is the first report of N. australe from fruit trees. PCR-RFLP analysis using the restriction endonucleases CfoI and HaeIII distinguished the major clades. However, two groups of closely related species, N. ribis and N. parvum, and N. australe and N. luteum (= B. lutea), had identical RFLP profiles. Using RFLP, it was shown that ¿Botryosphaeria¿ obtusa is the dominant species on fruit trees in the Western Cape Province of South Africa. These results and methods will be useful in future epidemiological studies and disease management of Botryosphaeriaceae from fruit trees.