EvidenceAlerts

Neuen BL, Young T, Heerspink HJL, et al. SGLT2 inhibitors for the prevention of kidney failure in patients with type 2 diabetes: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2019 Nov;7(11):845-854. doi: 10.1016/S2213-8587(19)30256-6. Epub 2019 Sep 5. (Systematic review)
Abstract

BACKGROUND: The effects of sodium-glucose co-transporter-2 (SGLT2) inhibitors on kidney failure, particularly the need for dialysis or transplantation or death due to kidney disease, is uncertain. Additionally, previous studies have been underpowered to robustly assess heterogeneity of effects on kidney outcomes by different levels of estimated glomerular filtration rate (eGFR) and albuminuria. We aimed to do a systematic review and meta-analysis to assess the effects of SGLT2 inhibitors on major kidney outcomes in patients with type 2 diabetes and to determine the consistency of effect size across trials and different levels of eGFR and albuminuria.

METHODS: We did a systematic review and meta-analysis of randomised, controlled, cardiovascular or kidney outcome trials of SGLT2 inhibitors that reported effects on major kidney outcomes in people with type 2 diabetes. We searched MEDLINE and Embase from database inception to June 14, 2019, to identify eligible trials. The primary outcome was a composite of dialysis, transplantation, or death due to kidney disease. We used random-effects models to obtain summary relative risks (RRs) with 95% CIs and random-effects meta-regression to explore effect modification by subgroups of baseline eGFR, albuminuria, and use of renin-angiotensin system (RAS) blockade. This review is registered with PROSPERO (CRD42019131774).

FINDINGS: From 2085 records identified, four studies met our inclusion criteria, assessing three SGLT2 inhibitors: empagliflozin (EMPA-REG OUTCOME), canagliflozin (CANVAS Program and CREDENCE), and dapagliflozin (DECLARE-TIMI 58). From a total of 38 723 participants, 252 required dialysis or transplantation or died of kidney disease, 335 developed end-stage kidney disease, and 943 had acute kidney injury. SGLT2 inhibitors substantially reduced the risk of dialysis, transplantation, or death due to kidney disease (RR 0·67, 95% CI 0·52-0·86, p=0·0019), an effect consistent across studies (I2=0%, pheterogeneity=0·53). SGLT2 inhibitors also reduced end-stage kidney disease (0·65, 0·53-0·81, p<0·0001), and acute kidney injury (0·75, 0·66-0·85, p<0·0001), with consistent benefits across studies. Although we identified some evidence that the proportional effect of SGLT2 inhibitors might attenuate with declining kidney function (ptrend=0·073), there was clear, separate evidence of benefit for all eGFR subgroups, including for participants with a baseline eGFR 30-45 mL/min per 1·73 m2 (RR 0·70, 95% CI 0·54-0·91, p=0·0080). Renoprotection was also consistent across studies irrespective of baseline albuminuria (ptrend=0·66) and use of RAS blockade (pheterogeneity=0·31).

INTERPRETATION: SGLT2 inhibitors reduced the risk of dialysis, transplantation, or death due to kidney disease in individuals with type 2 diabetes and provided protection against acute kidney injury. These data provide substantive evidence supporting the use of SGLT2 inhibitors to prevent major kidney outcomes in people with type 2 diabetes.

FUNDING: None.

Ratings
Discipline Area Score
Nephrology 7 / 7
Family Medicine (FM)/General Practice (GP) 7 / 7
General Internal Medicine-Primary Care(US) 7 / 7
Internal Medicine 6 / 7
Endocrine 6 / 7
Comments from MORE raters

Endocrine rater

More definitive evidence of renoproctective effects of SGLT2 inhibitors in patients with diabetes.

Endocrine rater

Chronic kidney disease (CKD) is a dreadful microvascular complication and is progressive in nature. Until recently, the use of ACEIs or ARBs were the key corner strategy to reduce progression to ESKD. This landmark trial shows that empagliflozin, canagliflozin, and dapagliflozin are highly beneficial to reduce/prevent progression from early and usually asymptomatic stages of CKD to stage 5 in patients with T2DM. This article should have good clinical implications.

Internal Medicine rater

The benefit of this article to me as a hospitalist and part-time endocrinology and metabolism specialist is that it provides evidence when I am asked to give an opinion or advice to my colleagues.

Nephrology rater

The addition of the CREDENCE trial results strengthens the conclusions in this meta-analysis that shows large renal benefits from using SGLT2 inhibitors. CREDENCE in particular showed the benefits of SGLT2 inhibitors in the low-eGFR group giving hope that this class of drugs could be safely used in this population.
Comments from EvidenceAlerts subscribers

No subscriber has commented on this article yet.