Search

Glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) have gained increasing attention for their potential benefits in people with type 2 diabetes mellitus (T2DM) with chronic kidney disease (CKD). Most supportive evidence of a kidney‐protective effect of the GLP‐1RA class of medications has been derived from kidney‐related outcomes reported from cardiovascular outcome trials (CVOTs). GLP‐1RAs have been shown to reduce albuminuria, mitigate cardiovascular risk, and possibly attenuate estimated glomerular filtration rate (eGFR) decline. The kidney‐protective effects of GLP‐1RAs are thought to be attributed to their anti‐inflammatory, antioxidant, and vasodilatory properties. Despite these promising findings, the use of GLP‐RAs has yet to be definitively shown to slow progression to chronic kidney failure in people with T2DM. The Research Study to See How Semaglutide Works Compared to Placebo in People With Type 2 Diabetes and Chronic Kidney Disease (FLOW trial) is the first major trial assessing the potential of a GLP‐1RA to slow progression of kidney disease in people with established CKD to clinically important kidney end points. On March 5, 2024, the top line result from FLOW was announced with semaglutide 1.0 mg being reported to reduce the primary end point of the trial by a significant 24% compared with placebo. Here, we summarize the kidney outcomes reported from CVOTs for the GLP‐1RA class of medication and briefly describe kidney outcomes from other major GLP‐1RAs trials. We also discuss a potential role of the dual GLP‐1/glucose‐dependent insulinotropic polypeptide (GIP) receptor agonist, tirzepatide, as a kidney‐protective agent. [ABSTRACT FROM AUTHOR]

Background: Adrenal vein sampling (AVS), integral to identifying surgically remediable unilateral primary aldosteronism (PA), is technically challenging and subject to fluctuations in cortisol and aldosterone secretion. Intra‐procedural adrenocorticotropic hormone (ACTH), conventionally administered as a 250‐μg bolus and/or 50 μg per hour infusion, increases cortisol and aldosterone secretion and can improve AVS success, but may cause discordant lateralisation compared to unstimulated AVS. Aims: To assess if AVS performed with ultra‐low dose ACTH infusion causes discordant lateralisation. Methods: Here, we describe our preliminary experience using an ultra‐low dose ACTH infusion AVS protocol. We retrospectively reviewed the results of consecutive AVS procedures (n = 37) performed with and without ultra‐low dose ACTH (1‐μg bolus followed by 1.25 μg per hour infusion). Results: Bilateral AV cannulation was successful in 70% of procedures pre‐ACTH and 89% post‐ACTH (p < 0.01). Sixty‐nine percent of studies lateralised pre‐ACTH and 55% post‐ACTH, improving to 79% when both groups were combined. Lateralisation was discordant in 11 cases, including eight in which lateralisation was present only on basal sampling, and three in which lateralisation occurred only with ACTH stimulation. Discussion: Overall, the decrease in lateralisation rates with ACTH was higher than previously reported for some protocols utilising conventional doses of ACTH. Our results suggest that AVS performed with ultra‐low dose ACTH can cause discordant lateralisation similar to AVS performed with conventional doses of ACTH. Conclusion: Prospective studies directly comparing low and conventional dose ACTH AVS protocols and long‐term patient outcomes are needed to help define the optimal ACTH dose for accurate PA subtyping. [ABSTRACT FROM AUTHOR]

Glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) have gained increasing attention for their potential benefits in people with type 2 diabetes (T2DM) with chronic kidney disease (CKD). This class of medication has demonstrated promising results in reducing albuminuria, preserving estimated glomerular filtration rate (eGFR), and mitigating cardiovascular (CV) risk, making them potential therapeutic options for individuals with CKD. The kidney protective effects of GLP‐1RAs extend beyond glycaemic control, and are thought to be attributed to their anti‐inflammatory, antioxidant, and natriuretic properties. Despite these promising findings, the use of GLP‐RAs has yet to be definitively shown to slow progression to chronic kidney failure, or reduce CV and kidney related death in people with T2DM and CKD. The Research Study to See How Semaglutide (a once weekly subcutaneous administered GLP‐1RA) Works Compared to Placebo in People with Type 2 Diabetes and Chronic Kidney Disease (FLOW trial) was recently stopped because of efficacy. The primary end point for the FLOW trial consists of a composite endpoint of (i) onset of chronic kidney failure; (ii) death from kidney failure; (iii) cardiovascular death; and (iv) onset of a persistent ≥50% reduction in eGFR from baseline. It has also been reported by the sponsors of the trial that the primary end point of the trial was reduced by 24% with both CKD and CV outcomes contributing to risk reduction. In anticipation of the results of the FLOW trial being published, we review the current evidence surrounding kidney outcomes and proposed kidney protective pathways associated with GLP‐1RA use. Summary at a glance: In anticipation of the results of a dedicated kidney outcome study of the GLP‐1RA semaglutide in people with type 2 diabetes and established chronic kidney disease (the FLOW trial) being released sometime in 2024, here we review the current evidence surrounding kidney outcomes and proposed kidney protective pathways associated with GLP‐1RA use. [ABSTRACT FROM AUTHOR]

The article case study of a 41-year-old man with longstanding type 1 diabetes who presented with severe ketoacidosis and lactic acidosis following vomiting. Topics include the diagnosis of emphysematous gastritis revealed by contrast-enhanced CT, its risk factors such as diabetes and gastric pneumatosis, and the management strategy involving gastroscopy and damage control total gastrectomy due to necrotic stomach tissue.

Background and Aims: Automated insulin delivery (AID) improves glycaemia among people with type 1 diabetes in clinical trials and overseas real‐world studies. Whether improvements are sustained beyond 12 months in the real world, and whether they occur in the Australian context, has not yet been established. We aimed to observe, up to 2 years, the effectiveness of initiating first‐generation AID for type 1 diabetes management. Methods: Retrospective, real‐world, observational study using medical records, conducted across five sites in Australia. Adults with type 1 diabetes, who had AID initiated between February 2019 and December 2021, were observed for 6–24 months after initiation (until June 2022). Outcomes examined included glucose metrics assessed by glycated haemoglobin (HbA1c) and continuous glucose monitoring (CGM), safety and therapy continuation. Results: Ninety‐four adults were studied (median age 39 years (interquartile range, IQR: 31–51); pre‐initiation HbA1c 7.8% (7.2–8.6)). After AID initiation, HbA1c decreased by mean 0.5 percentage points (95% confidence interval (CI): −0.7 to −0.2) at 3 months (P < 0.001); CGM time in range 3.9–10.0 mmol/L increased by 11 percentage points (9–14) at 1 month (P < 0.001); these improvements were maintained up to 24 months (all P < 0.02). Median CGM time below 3.9 mmol/L was <1.5% pre‐ and post‐AID initiation. The subgroup with pre‐initiation HbA1c above 8.5% had the greatest HbA1c improvement (−1.4 percentage points (−1.8 to −1.1) at 3 months). Twelve individuals (13%) discontinued AID, predominantly citing difficulties with CGM. During the 150 person‐years observed, four diabetes‐related emergencies were documented: three severe hypoglycaemic events and one hyperglycaemic event without ketoacidosis. Conclusions: Early glucose improvements were observed after real‐world AID initiation, sustained up to 2 years, without excess adverse events. The greatest benefits were observed among individuals with highest glycaemia before initiation. Future‐generation systems with increased user‐friendliness may enhance therapy continuation. [ABSTRACT FROM AUTHOR]