Thread by @ckd_ce

1) Welcome to this new #accredited #tweetorial on “Strategies to Apply Current Clinical Trial Data for SGLT2i to Reduce the Progression of CKD,” authored by our ⭐️tweetorialist Edgar V. Lerma 🇵🇭 @edgarvlermamd

2) This program is #accredited for CE/#CME #physicians #physicianassociates #nurses #pharmacists #nursepractitioners & is supported by an educational grant from the Boehringer Ingelheim Pharmaceuticals Inc and Eli Lilly Company. It is intended for healthcare professionals.

3) Faculty disclosures and statement of accreditation are provided at ckd-ce.com/disclosures/. Please FOLLOW @ckd_ce (& @cardiomet_CE!) so you don't miss ANY of our unique serialized #tweetorials, always 🆓, always from expert authors! Prior programs at ckd-ce.com/category/dkd/ .

4) A case to start: 50♂️ with underlying type 2 diabetes (#T2D) and hypertension (#HTN) comes to your office for #CKD F/U. He has been diabetic for 20+ years and has #retinopathy and #neuropathy.
He is on amlodipine, chlorthalidone, glipizide, insulin, losartan, metformin.

5) Vital stats:
👉#UACR 1000 mg/g
👉#eGFR 31 mL/min/1.73 m2
👉BP 138/70
👉#A1C 7.6% (60 mmol/mol)

6) According to the @AmDiabetesAssn and @goKDIGO consensus, #SGLT2i are recommended in most patients with #T2D and #CKD with eGFR >/= 20 mL/min/1.73 m2 independent of HbA1c or the need for additional glucose lowering
👉 🔓pubmed.ncbi.nlm.nih.gov/36202661/

7) This recommendation is based on strong evidence that #SGLT2i reduce #CKD progression, #HF, and #ASCVD risk in patients with #T2D and CKD
#VisualAbstract by @brendonneuen @whatsthegfr

#CREDENCE 🔓pubmed.ncbi.nlm.nih.gov/30990260/

DAPA_CKD 🔓pubmed.ncbi.nlm.nih.gov/32970396/

8) These trials enrolled pts w/ #albuminuria:
#CREDENCE: ACR >/=300 mg/g
#DAPA_CKD: ACR >/=200 mg/g
& showed significant benefit for composite outcomes/EPs:
📌 Substantial eGFR ⬇️
📌 Kidney failure
📌 Mortality

CREDENCE pubmed.ncbi.nlm.nih.gov/30990260/
DAPA-CKD pubmed.ncbi.nlm.nih.gov/32970396/

9) Current evidence is strongest in this population, as emphasized by @AmDiabetesAssn recommendations
👉🔓 pubmed.ncbi.nlm.nih.gov/36202661/

10) There is evidence from combined major #SGLT2i trials, however, suggesting that kidney and #CV benefits are consistent "irrespective of baseline #albuminuria"
👉🔓 pubmed.ncbi.nlm.nih.gov/31495651/
👉🔓 pubmed.ncbi.nlm.nih.gov/33222693/

11) This @JASN_News paper ➡️ relative effects of #canagliflozin on #renal & #CV outcomes are mostly consistent "across different levels of baseline albuminuria," but participants w/ severely increased #albuminuria saw the largest absolute benefits
👉🔓 pubmed.ncbi.nlm.nih.gov/31530577/

12) The lower limit of #eGFR for which initiation of #SGLT2i is recommended has changed over time as new data have rapidly become available

13) The @goKDIGO 2022 guideline recommended initiation of an #SGLT2i for patients with #T2D and #CKD who have #eGFR >/= 20 (a change from >/= 30 in the 2020 guideline)
👉🔓 pubmed.ncbi.nlm.nih.gov/36202661/

14) The @AmDiabetesAssn has also updated this threshold to >/= 20 in its living Standards of Care (from >/= 25 in the initial issue of the 2022 Standards of Care)
👉🔓 pubmed.ncbi.nlm.nih.gov/36202661/

15) These changes are driven largely by findings of new trials, including the #DAPA_CKD trial (which provided clear evidence of efficacy and safety for #dapagliflozin in patients with #eGFR >/= 25 and #ACR >/= 200 mg/g)
DAPA-CKD: 🔓pubmed.ncbi.nlm.nih.gov/32970396/

16) #Empagliflozin Outcome Trials in Patients w/ Chronic HF (EMPEROR) provided clear evidence of efficacy & safety for empa in patients w/ #eGFR >/= 20 & HF
#VisualAbstract by @whatsthegfr
#EMPEROR_Preserved 🔓pubmed.ncbi.nlm.nih.gov/34449189/
#EMPEROR_Reduced 🔓pubmed.ncbi.nlm.nih.gov/32865377/

17) Additional support comes from subgroup analyses of participants in the #CREDENCE and #DAPA_CKD trials with baseline eGFR <30
#VisualAbstract by @divyaa24

👉 @CJASN 🔓 pubmed.ncbi.nlm.nih.gov/33214158/
👉 @JASN_News 🔓pubmed.ncbi.nlm.nih.gov/34272327/

18) Evidence supporting initiation of an #SGLT2i for patients with #T2D and #eGFR 20–29 mL/min/1.73 m2 is strongest for patients with concomitant #albuminuria or #HF
👉 🔓pubmed.ncbi.nlm.nih.gov/34272327/
👉 🔓pubmed.ncbi.nlm.nih.gov/33214158/
👉 🔓pubmed.ncbi.nlm.nih.gov/31495651/

19) #SGLT2i have been observed to have consistent efficacy and safety across studied ranges of #eGFR
👉 pubmed.ncbi.nlm.nih.gov/31495651/

20) See the areas of overlap for clinical trials with #SGLT2i in patients with #CKD
👉 🔓pubmed.ncbi.nlm.nih.gov/31727290/

21) On the background of these trials, according to the @AmDiabetesAssn and @goKDIGO consensus, an #SGLT2i can be initiated for most patients with #T2D, #CKD, and #eGFR >/=20

22) In the much anticipated EMPA-KIDNEY trial (The Study of Heart & Kidney Protection w/Empagliflozin), entry criteria were expanded to include nonalbuminuric CKD with an eGFR initiation threshold >/= 20 among >6,600 participants +/- T2D
👉 @NDTsocial 🔓pubmed.ncbi.nlm.nih.gov/35238940/

23) Like #CREDENCE and #DAPA_CKD, #EMPA_KIDNEY was stopped early for clear positive #efficacy
👉 boehringer-ingelheim.com/human-health/m…

24a) So let's pause here for a knowledge check, knowing that @nephondemand @ChristosArgyrop @Sglt2inhibitorL @HecmagsMD @sophia_kidney all know the answer . . .
#FOAMed #NephTwitter @MedTweetorials

24b) In 2022, both @goKDIGO and @AmDiabetesAssn updated its threshold for initiating @Sglt2I in patients with #T2D to eGFR down to 20. Benefit at this lower level is most pronounced in patients with

25) Mark your response and RETURN TOMORROW for the correct answer and the remainder of this #tweetorial so that you can grab your 0.5hr 🆓CE/#CME! See you then!!