Search Medical Journals & Research Articles

Broader Adoption of SGLT2 Inhibitors in Clinical Practice

Over the past decade, the indications for sodium-glucose cotransporter 2 (SGLT2) inhibitors for kidney and cardiovascular risk reduction have expanded, driven by clinical trial evidence demonstrating their efficacy among individuals with chronic kidney disease (CKD), heart failure, diabetes, and atherosclerotic cardiovascular disease. Current clinical practice guidelines for people with CKD recommend their use for individuals with an estimated glomerular filtration rate (eGFR) greater than or equal to 20 mL/min/1.73 m2 who also have type 2 diabetes, heart failure, or a urine albumin to creatinine ratio (UACR) greater than 200 mg/g. A major unanswered question is whether SGLT2 inhibitors would improve kidney outcomes among those with lower degrees of albuminuria or more advanced CKD than recommended by current guidelines. To address this crucial knowledge gap, the SGLT2 Inhibitor Meta-Analysis Cardio-Renal Trialists’ Consortium (SMART-C) conducted 2 companion meta-analyses of randomized placebo-controlled SGLT2 inhibitor trials to assess the effect on kidney outcomes among key subgroups of patients and report their results in this issue of JAMA.

Divergent GFR Estimates and Clinical Implications

Chronic kidney disease (CKD) affects more than 800 million people worldwide, significantly increasing the risk for kidney failure, cardiovascular disease, and all-cause mortality. Accurate assessment of glomerular filtration rate (GFR) is essential for identifying and managing CKD. Although GFR is most accurately measured by analyzing the rate of kidney excretion of infused exogenous substances, such as inulin or iohexol, this is not practical in most cases. Therefore, estimated glomerular filtration rates (eGFRs) have become important for CKD diagnosis and management.

Prerenalism—A Gap That Costs Lives, Hearts, and Kidneys

Chronic kidney disease (CKD) is a powerful risk enhancer for cardiovascular disease (CVD) and exhibits a dose association for higher rates of death and adverse cardiovascular outcomes by declining strata of estimated glomerular filtration rate (eGFR) and increasing albuminuria. The recently defined cardiovascular-kidney-metabolic (CKM) syndrome highlights the overlapping pathophysiological mechanisms between obesity, diabetes, and CKD, which amplify CVD risk in tandem with adverse socio-ecological factors. The emerging array of highly efficacious therapies for CKM conditions represents a vast opportunity to modify the global burden of CVD by identifying and treating CKD, given their congruent cardiovascular-kidney benefits. Importantly, CVD and premature mortality are the major competing risks for kidney failure in individuals with diabetes and CKD, and cardiovascular and survival benefits may precede protection from kidney failure with CKM therapies in high-risk CKD populations.

A-E-I-O-U and Sometimes Why—Dialysis in Acute Kidney Injury

Students memorize the indications for dialysis in acute kidney injury (AKI) as the vowels of the alphabet, A-E-I-O-U: acidosis, electrolytes, ingestions, overload, and uremia. In a study published in JAMA, Liu and colleagues ask clinicians to consider the last vowel, sometimes Y (“why”), in their report of the LIBERATE-D trial testing a conservative vs conventional thrice-weekly strategy for dialysis for patients with AKI. A brief historical review of the evolution of strategies for kidney replacement therapy (KRT) will help put LIBERATE-D into context.

Sodium Bicarbonate in Severe Acidemia and Acute Kidney Injury

Severe acidemia commonly complicates critical illness. If unresolved or untreated, acidemia may exacerbate multiorgan dysfunction, prompt escalation in life support, and portend greater risk of adverse outcomes. Intravenous (IV) sodium bicarbonate is often used in clinical practice to buffer severe acidemia; however, existing evidence on its effectiveness remains inconclusive. The most recent iteration of the Surviving Sepsis Guidelines offers only a weak recommendation (low quality of evidence) for use of IV sodium bicarbonate therapy in patients with sepsis and shock, severe acidosis, and acute kidney injury (AKI). This recommendation was derived largely from the initial BICARICU trial, a multicenter, open-label, randomized clinical trial suggesting reduced mortality at 28 days and lower use of kidney replacement therapy (KRT) with IV sodium bicarbonate therapy in a prespecified subgroup of patients with severe acidemia (pH ≤7.20) and moderate to severe AKI.