A renowned specialist panel consisting of a cardiologist, ophthalmologist, neurologist and nephrologist discusses how to manage complications of diabetes - nephrology session.
Back to Symposium Page » Hello, everybody. And welcome back to our afternoon session, uh, incredibly exciting speakers that we had a great morning session and I'm looking forward to the afternoon session is Well, we're going to kick it off with a panel session. In past years, we've done this a times where we split out into breakout. And so not everybody can hear all the panel speakers. And recently we had them do a combined session and it worked really well. So I really wanted to do that again for this one. So everyone can hear all this new, exciting information that's coming out not just on diabetes, but all these parallel courses around the co morbid conditions. How some of these new medications are being affected to have some of the path of physiology is occurring earlier, as in Nash. Andi, how I nerve. Other things are affected as well. So our first speaker for this is Dr Kimberly Harper. She is an adult nephrologist with scripts Clinic Medical Group. She has an enormous amount of experience in this area. She also works with our transplant groups. So see things from that perspective, and I know she's excited to give us more information around what's been happening over the last year or two in this enormous explosion of information. So, Kim, I'm gonna turn it over to you. Great. Yes. Hello. Hello. Hello to everyone out there in this new virtual world that we're in. And yes, I am definitely very excited to be here to talk to you all about the very new and very, very exciting advances in the treatment of diabetic kidney disease. We are very, very excited in nephrology. We have a lot of optimism right now, and there is just ah lot of talk and a lot of excitement. And we now have, as you probably already know, a brand new class of medications that can slow progression of diabetic kidney disease and save lives. And if that wasn't enough, there are also a couple of other classes of medications that I'm going to mention briefly at the end there looking very, very promising. And we may be seeing those coming soon, but first off, I am going to focus in on the big news. I was just attending the American society nephrology virtual meetings, and this was what everyone was talking about. And yeah, what were we all talking about? If I could get my their radio? I have no disclosures. There we go. Sorry about that SGL T two inhibitors. It's a brand new class for us, and we are very, very excited to start using these agents. We now have not one but two renal outcome trials showing that these agents make a big difference. And today I'm going to briefly summarize those two studies. The one is credence, which I'm sure you've heard about It was published last year in The New England Journal of Medicine with Canada frozen and then also go over the newly published DAPA CKD study with difficult, frozen and just of note, look forward to seeing the MPA kidney study results when those come out. We're definitely looking forward to that. So the Credence trial. This is a landmark trial. I cannot emphasize how exciting and how important this trial is for us. In mythology, this is one for the mythology history books. It is a double blind, randomized controlled trial. They had over 4000 patients. Thes patients had Type two diabetes and diabetic kidney disease. They were stage two and stage three, chronic kidney disease and they had anywhere between 305,000 mg of albumin in their urine. They were all on standard therapy there on maximum dose of an ACE inhibitor or an angiotensin receptor blocker, and they randomized them to 100 mg of chemical frozen or a placebo. That primary renal outcome was a composite outcome that you can see there. It was a composite of end stage kidney disease transplant GF are less than 15 doubling Sam creating or death from renal or cardiovascular cause. And the two arms of this trial were nicely matched, and you can see their characteristics here. Their age was about 63. It was predominantly white patients involved in this study, about 67% 20% Asian and 5% black. And not surprisingly, half of the patients had cardiovascular disease. I actually probably would have assumed that would've been a higher percentage, Um, and the patients GF bars were around 56 they were spilling about 900 mg of albumin in their urine. Now what did they see? They saw something quite remarkable. Very, very impressive results so impressive that they stopped the study early because patients receiving canticle frozen. We're doing so much better than the patients receiving the placebo, and you can see that up here in the primary outcome. And here you have the percentage of patients achieving that primary outcome here, and this is time in months. And the placebo, of course, on top chemical frozen in the blue there. And boy, you can see a big difference in outcomes hazard ratio of 70%. Very impressive. You know, a 30% relative risk reduction. We don't see that everyday to kind of put it in perspective. If you recall the renowned study from almost 20 years ago, which showed that low certain was beneficial to patients with diabetic kidney disease on their primary composite outcome, the risk reduction was just 16%. And here we're seeing a 30% risk reduction. And of course, as you can see, looking through all the other outcomes as they have outlined, whether it's renal specific composite outcome and stage kidney disease, dialysis, kidney transplant, renal death, canticle, frozen patients did better, and very important is that these patients, these patients who received the STL T two inhibitors had better survival. So spl t two inhibitors save lives very important outcome, of course. And you can see death from cardiovascular cause, death from any cause and the hazard ratios. Their boy. These are amazing medications. Now, of course, you can take a look here and see the all the different outcomes as their outlined in a different format here. But if you look down, you can see a primary composite outcome. They broke it down by G. F. R s and baseline albumin urea. You can see the renal specific outcomes all those outlined here. And yes, everything's over on this side. Meaning, of course, that patients receiving canticle flows and did better. Of course, that was one study, and now we have yet another study showing us the benefits of the STL t two inhibitors. This study was just published last month in the New England Journal of Medicine. The DAPA CKD study, Another good study, double blind randomized controlled trial. But there was a big different than the credence study. There were a couple of differences that are important to note. One is in this study. They looked at patients who had mawr advanced kidney disease. So in the credence study, the average VFR was around 56 in this study, the average was lower. It was in the low forties, 42 43 they accepted patients with G F. R s down to 25. Yeah, please note that they were taking patients with pretty advanced kidney disease. They also took patients that didn't have much albumin in their urine down to 200. And another really striking. Part of the design of this study was that they took patients that did not have diabetes. So one third of the patients enrolled in the study did not have diabetes. The other two thirds, of course, did. And just like the credence trial, these patients were all on standard therapy. They were on their maximum dose of their ace inhibitor or their angiotensin receptor blocker, and they were randomized to dapa glow frozen versus placebo. And you can see the primary outcome there. A decline in G f R and stage kidney disease or death from renal or cardiovascular causes. And lo and behold, just like the credence trial. This study was stopped early because there was such a dramatic difference in outcomes, and in this study, the hazard ratio was even better at 0.61 39% risk reduction when you received capital flows in very, very impressive. And you can see it how it and all these other outcomes the same type of results. Yeah, and this slide is a nice slide to show you what happens with your GF are when you get started on an SGL t two inhibitor. This one is for DAP ical frozen, but it might as well be the same. One is it's the same graph for em pickle frozen or canticle frozen. And interestingly enough, it is also the same graph that you see when you start somebody on an ACE inhibitor or an angiotensin receptor blocker. So nephrologist are very, very comfortable with looking at this type of a graph, and you can see that Yes, the GF are drops initially, but we tolerate that just as we do with an ace inhibitor, because we know that at some point those lines cross and ultimately down the road. Patients receiving the SLT two inhibitor have better preserved kidney function than those that do not. And so bottom line on this one is that for any of us who are taking care of patients with diabetic kidney disease. Whether it's a primary care doctor, nephrologist and endocrinologist, you name it if you have someone with diabetic kidney disease and they're on maximum dose of their ace inhibitor, the angiotensin receptor blocker GF are in the 25 to 89 range albumin, urea and the 200 to 5000 mg range. We really need to think about prescribing SGL T two inhibitors. We need to get comfortable with using these agents, and I'm going to briefly talk about I don't want to go over my time. Um, some exciting news about a different class of medications. These are the nonsteroidal selective mineral Corta coid receptor antagonistic. The narrow known the Fidelio D K D trial was also just published recently, and it was another double blind, nicely designed tri ALS patients. Again, we're on maximum dose of their ace inhibitor, angiotensin receptor blocker and looking at a primary renal outcome. They were randomized, placebo, orphan aren on and they also showed benefit in the primary renal outcome, and you can see that up here with a hazard ratio. 0.82 patients receiving this Middle court accord receptor antagonistic did better than those receiving placebo and looking at kind of breaking down all the outcomes here. You can see that with the exception of non fatal stroke, pretty much everything looks much better when you receive the phenomenon. One of the concerns, of course, about a mineral court record. Receptor antagonists. Hyper Cally Mia. Obviously your patients with chronic kidney disease can get hyper. Colima Diabetics are particularly prone because they have type. They could get type for our T A. They're already on an ACE inhibitor or an angiotensin receptor blocker, and then you add another agent and boy. We could run into some trouble with potassium, so, of course, they were carefully watching and monitoring potassium. During the trial. You could not have a potassium above 4.8 and enter into the trial, and they did see and track potassium and found that they were on the higher end in those patients receiving the middle court accord receptor antagonistic so mawr to come on. This one there is an ongoing study. Ah, largest. I think it's actually think about the same size of a study, and this study I will, should be coming out soon with more data and last but not least, GLP one receptor agonists. There is an ongoing flow study looking at those in kidney disease. We look forward to seeing those results and I thank you for your attention.