Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

Background: The EMPA KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. Methods: EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. Findings: Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5–2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62–0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16–1·59), representing a 50% (42–58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). Interpretation: In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. Funding: Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council

Phytase enzyme in diets containing defatted rice bran for growing swine Enzima fitase dietas com farelo de arroz desengordurado para suínos em crescimento

Organic phosphorus is poorly utilized by monogastric animals because they lack phytase, the enzyme that cleaves the ortho-phosphate groups from the phytate molecule. Diets fed to pigs are supplemented with inorganic P, and this can increase environmental pollution and diet costs. Sixty mixed sex, half-breed pigs, were used to evaluate the effect of increasing dietary levels of phytase (253, 759, 1265 and 1748 PU kg-1 feed) on animal performance as compared to a control without phytase but supplemented with dicalcium phosphate. Enzyme levels did not affect daily feed intake, food conversion, average daily weight gain, plasma P and Ca, calcium and phosphorus in bone ash, and the calcium/phosphorus ratio in the plasma and bones. A quadratic relationship between phytase levels and the percentages of P and Ca in bone ash was observed, reaching a maximum at the 880 and 879 PU levels, respectively. Animals fed diets containing phytase presented low plasma P values when compared to the control, but no effects were observed for the regression analysis. Using 759 PU phytase in rations containing corn, soybean bran and defatted rice bran for growing pigs can eliminate the use of traditional sources of P.<br>Os animais monogástricos não aproveitam eficientemente o P orgânico das dietas, pois não sintetizam a enzima fitase, sendo necessária a suplementação das rações com P inorgânico, podendo elevar o custo das dietas e a poluição ambiental. Foram utilizados 60 leitões mestiços (machos castrados e fêmeas) para avaliar a eficácia dos níveis dietéticos crescentes da enzima fitase (253, 759, 1265 e 1748 UF kg-1 de ração) sobre os parâmetros de desempenho e comparar com o tratamento testemunha que diferia dos demais por não conter fitase e por conter fosfato bicálcico. Os níveis da enzima fitase não afetaram o consumo diário de ração, conversão alimentar, ganho diário de peso, P e Ca no plasma, cinzas no osso e relação cálcio e fósforo no plasma e osso. Observou-se relação quadrática entre os níveis dietéticos de fitase e a porcentagem de P e Ca nas cinzas ósseas, com ponto de maximo no nível de 880 e 879 UF respectivamente. As dietas com fitase propiciaram valores inferiores para o fósforo no plasma quando comparados com o tratamento testemunha, mas não apresentaram efeitos para análise de regressão. A utilização de 759 UF em rações à base de milho, farelo de soja e farelo de arroz desengordurado para suínos na fase de crescimento permite a eliminação das fontes tradicionais de P

Fluxo biológico do fósforo no metabolismo de suínos alimentados com dietas contendo fitase Biological P flow on metabolism of pigs fed diets containg phytase

A pesquisa foi conduzida para avaliar o fluxo biológico do P em suínos, na fase de crescimento, alimentados com dietas à base de milho, farelo de soja, farelo de arroz desengordurado e óleo de soja, isentas de P inorgânico e suplementadas com níveis crescentes de fitase (253, 759, 1.265 e 1.748 UF/kg de dieta), e destacar o melhor nível de utilização da enzima, usando modelos matemáticos. O modelo utilizado foi determinístico e compartimental, em que o trato gastrintestinal (C1), o plasma C2, os ossos (C3) e os tecidos moles (ossos, coração, figado, rins e músculos), estudados em conjunto (C4), representaram os compartimentos. Foram utilizados dados de metabolismo e cinética do P nos tecidos, obtidos pela técnica de diluição isotópica. Os parâmetros estimados foram: absorção, retenção, P endógeno que retorna ao trato gastrintestinal, P dietético absorvido, incorporação, reabsorção, balanço de P, P proveniente do osso, dos tecidos moles e do total absorvido que retorna ao trato gastrintestinal. o modelo biomatemático utilizado mostrou-se eficiente em explicar o fluxo do fósforo no organismo de suínos em crescimento. A fitase interferiu no fluxo biológico do P do compartimento C1 para o C3 e no refluxo dos compartimentos C3 e C4 para o C1. O nível 759 UF/kg de ração disponibilizou mais eficientemente o fósforo orgânico para o metabolismo dos suínos.<br>The study was conducted to evaluate the biological flow of P in pigs fed diets based on corn, soybean meal, defatted rice bran (DRB) and soybean oil, with increasing phytase levels (253, 759, 1265 and 1748 PU/kg of diet), using mathematics models. The model was deterministic and compartimental, in which the gastrintestinal tract (GIT) (C1), the plasma C2, the bones (C3) and the soft tissues (liver, heart, kidney and muscle) (C4) represented the compartments. Metabolism data and kinetics of P in tissues were used in the model, obtained by the isotopic dilution technique. The parameters used were: absorption, retention, endogenous P that return to the gastrintestinal tract (GIT), dietary absorbed P, accretion, reabsorption, balance of P in bone and soft tissues and P from total absorbed that returned the GIT. The biomathematical model used is adequate to explain the P flow in growing pig. The phytase enzyme interfere in biological flow of P from compartment C1 to C3 and with the output flow of P from compartment C3 and C4 to C1. The level of 759 PU of phytase in diet of growing pig availability more efficientily the organic phosphorus for the pigs metabolism

Predicting Kidney Failure, Cardiovascular Disease and Death in Advanced CKD Patients

Introduction: Predicting the timing and occurrence of kidney replacement therapy (KRT), cardiovascular events, and death among patients with advanced chronic kidney disease (CKD) is clinically useful and relevant. We aimed to externally validate a recently developed CKD G4+ risk calculator for these outcomes and to assess its potential clinical impact in guiding vascular access placement. Methods: We included 1517 patients from the European Quality (EQUAL) study, a European multicentre prospective cohort study of nephrology-referred advanced CKD patients aged ≥65 years. Model performance was assessed based on discrimination and calibration. Potential clinical utility for timing of referral for vascular access placement was studied with diagnostic measures and decision curve analysis (DCA). Results: The model showed a good discrimination for KRT and “death after KRT,” with 2-year concordance (C) statistics of 0.74 and 0.76, respectively. Discrimination for cardiovascular events (2-year C-statistic: 0.70) and overall death (2-year C-statistic: 0.61) was poorer. Calibration was fairly accurate. Decision curves illustrated that using the model to guide vascular access referral would generally lead to less unused arteriovenous fistulas (AVFs) than following estimated glomerular filtration rate (eGFR) thresholds. Conclusion: This study shows moderate to good predictive performance of the model in an older cohort of nephrology-referred patients with advanced CKD. Using the model to guide referral for vascular access placement has potential in combating unnecessary vascular surgeries

Association Between Renal Function and Troponin T Over Time in Stable Chronic Kidney Disease Patients

Background-People with reduced glomerular filtration rate (GFR) often have elevated cardiac troponin T (cTnT) levels. It remains unclear how cTnT levels develop over time in those with chronic kidney disease (CKD). The aim of this study was to prospectively study the association between cTnT and GFR over time in older advanced-stage CKD patients not on dialysis.Methods and Results-The EQUAL (European Quality Study) study is an observational prospective cohort study in stage 4 to 5 CKD patients aged >= 65 years not on dialysis (incident estimated GFR, <20 mL/min/1.73 m(2)). The EQUAL cohort used for the purpose of this study includes 171 patients followed in Sweden between April 2012 and December 2018. We used linear mixed models, adjusted for important groups of confounders, to investigate the effect of both measured GFR and estimated GFR on high-sensitivity cTnT (hs-cTnT) trajectory over 4 years. Almost all patients had at least 1 hs-cTnT measurement elevated above the 99th percentile of the general reference population (<= 14 ng/L). On average, hs-cTnT increased by 16%/year (95% CI, 13-19; P<0.0001). Each 15 mL/min/1.73 m(2) lower mean estimated GFR was associated with a 23% (95% CI, 14-31; P<0.0001) higher baseline hs-cTnT and 9% (95% CI, 5-13%; P<0.0001) steeper increase in hs-cTnT. The effect of estimated GFR on hs-cTnT trajectory was somewhat lower than a previous myocardial infarction (15%), but higher than presence of diabetes mellitus (4%) and male sex (5%).Conclusions-In CKD patients, hs-cTnT increases over time as renal function decreases. Lower CKD stage (each 15 mL/min/1.73 m2 lower) is independently associated with a steeper hs-cTnT increase over time in the same range as other established cardiovascular risk factors.Diabetes mellitus: pathophysiological changes and therap

Kidney failure prediction models: A comprehensive external validation study in patients with advanced CKD

Background Various prediction models have been developed to predict the risk of kidney failure in patients with CKD. However, guideline-recommended models have yet to be compared head to head, their validation in patients with advanced CKD is lacking, and most do not account for competing risks. Methods To externally validate 11 existing models of kidney failure, taking the competing risk of death into account, we included patients with advanced CKD from two large cohorts: the European Quality Study (EQUAL), an ongoing European prospective, multicenter cohort study of older patients with advanced CKD, and the Swedish Renal Registry (SRR), an ongoing registry of nephrology-referred patients with CKD in Sweden. The outcome of the models was kidney failure (defined as RRT-treated ESKD). We assessed model performance with discrimination and calibration. Results The study included 1580 patients from EQUAL and 13,489 patients from SRR. The average c statistic over the 11 validated models was 0.74 in EQUAL and 0.80 in SRR, compared with 0.89 in previous validations. Most models with longer prediction horizons overestimated the risk of kidney failure considerably. The 5-year Kidney Failure Risk Equation (KFRE) overpredicted risk by 10%-8%. The four- and eight-variable 2-year KFRE and the 4-year Grams model showed excellent calibration and good discrimination in both cohorts. Conclusions Some existing models can accurately predict kidney failure in patients with advanced CKD. KFRE performed well for a shorter time frame (2 years), despite not accounting for competing events. Models predicting over a longer time frame (5 years) overestimated risk because of the competing risk of death. The Grams model, which accounts for the latter, is suitable for longer-term predictions (4 years)

Associations between depressive symptoms and disease progression in older patients with chronic kidney disease: Results of the EQUAL study

Background: Depressive symptoms are associated with adverse clinical outcomes in patients with end-stage kidney disease; however, few small studies have examined this association in patients with earlier phases of chronic kidney disease (CKD). We studied associations between baseline depressive symptoms and clinical outcomes in older patients with advanced CKD and examined whether these associations differed depending on sex. Methods: CKD patients (≥65 years; estimated glomerular filtration rate ≤20 mL/min/1.73 m2) were included from a European multicentre prospective cohort between 2012 and 2019. Depressive symptoms were measured by the five-item Mental Health Inventory (cut-off ≤70; 0-100 scale). Cox proportional hazard analysis was used to study associations between depressive symptoms and time to dialysis initiation, all-cause mortality and these outcomes combined. A joint model was used to study the association between depressive symptoms and kidney function over time. Analyses were adjusted for potential baseline confounders. Results: Overall kidney function decline in 1326 patients was -0.12 mL/min/1.73 m2/month. A total of 515 patients showed depressive symptoms. No significant association was found between depressive symptoms and kidney function over time (P = 0.08). Unlike women, men with depressive symptoms had an increased mortality rate compared with those without symptoms [adjusted hazard ratio 1.41 (95% confidence interval 1.03-1.93)]. Depressive symptoms were not significantly associated with a higher hazard of dialysis initiation, or with the combined outcome (i.e. dialysis initiation and all-cause mortality). Conclusions: There was no significant association between depressive symptoms at baseline and decline in kidney function over time in older patients with advanced CKD. Depressive symptoms at baseline were associated with a higher mortality rate in men