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  • (2022) Neuen, Brendon
    Type 2 diabetes is a major global health issue. It is projected that by 2045, 783 million people worldwide will be living with diabetes, making it one of the leading contributors to premature death globally. Approximately 30 to 40% of individuals with diabetes develop chronic kidney disease (CKD), making diabetes the leading cause of CKD worldwide. Despite glucose, blood pressure and lipid lowering, and treatment with renin-angiotensin system (RAS) blockade, the risk of cardiovascular events, kidney failure and death remains high for millions of people with diabetes and CKD worldwide. Originally developed to lower blood glucose, sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to have favourable effects on multiple metabolic risk factors including blood pressure, glucose, body weight and albuminuria. Large, randomized trials, including those reported herein, have demonstrated the capacity of these agents to reduce the risk of cardiovascular events, kidney failure and extend survival in increasingly diverse populations, including those without diabetes. This doctorate aims to evaluate the efficacy and safety of SGLT2 inhibitors in people with type 2 diabetes and CKD. Chapter 1 introduces the doctorate, summarizing the epidemiology of type 2 diabetes and CKD, as well as traditional approaches to improving outcomes in this population and the potential role for SGLT2 inhibition in people with diabetes. Chapter 2 provides an overview of SGLT2 inhibitors, practical considerations and evidence for their use in people with type 2 diabetes from cardiovascular outcome trials. Chapters 3 to 5 assess the efficacy and safety of the SGLT2 inhibitor, canagliflozin, across different levels of kidney function, defined by estimated glomerular filtration rate (eGFR) and albuminuria, using data from the CANVAS Program. Whilst the relative effects of canagliflozin on cardiovascular and kidney outcomes are consistent across different levels of eGFR and albuminuria, absolute risk reductions are largest for individuals with severely increased albuminuria. Further, the Kidney Disease Improving Global Outcomes classification of CKD, which combines eGFR and albuminuria to risk stratify individuals, can accurately identify those who are likely to derive the greatest absolute benefits with treatment. In Chapter 6, the results of a systematic review and meta-analysis are presented, which demonstrate that for people with type 2 diabetes, SGLT2 inhibitors substantially reduce the risk of the most important patient-centred kidney outcome – the need for dialysis, kidney transplantation or death due to kidney disease – and provide protection against acute kidney injury. The results of a meta-analysis are presented in Chapter 7, indicating that the benefits of SGLT2 inhibitors are similar with and without metformin, which is widely recommended as first-line glucose lowering therapy in type 2 diabetes. In Chapter 8, an individual participant data meta-analysis demonstrated that SGLT2 inhibitors reduce the risk of serious hyperkalaemia in people with type 2 diabetes at high cardiovascular risk and/or with CKD, which may enable better use of RAS blockade and mineralocorticoid receptor antagonists to improve cardiorenal outcomes. Chapter 9 explores questions about this class of agent that remain to be answered by ongoing randomized trials, and how SGLT2 inhibitors and other kidney protective therapies might be used for people with CKD in the future. Taken together, the findings of this doctorate provide compelling evidence that SGLT2 inhibitors should be routinely offered to individual with type 2 diabetes to safely reduce the risk of major kidney outcomes and cardiovascular events.