Multidisciplinary endocrinology and nephrology care in the DKD clinic is associated with a lower risk of end-stage renal disease. These findings may inform future management strategies targeted at patients with T2DM and CKD, especially with regard to joint specialist management involving endocrinologists and nephrologists.
Background Randomised controlled trials have demonstrated the benefits of sodium-glucose co-transporter 2 inhibitors (SGLT2is) in people with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). However, real-world data on CKD progression and the development of end-stage kidney disease (ESKD) remains scarce. We aim to study renal outcomes of people with diabetic kidney disease (DKD) using SGLT2is in a highly prevalent DKD population. Methods Between 2016 and 2019, we recruited T2DM patients in the renal or diabetic clinic in a regional hospital in Singapore. Patients prescribed SGLT2is were compared with those on standard anti-diabetic and reno-protective treatment. The outcome measures were CKD progression (a > = 25% drop from baseline and worsening of estimated glomerular filtration rate (eGFR) categories according to KDIGO guidelines) and ESKD (eGFR < 15ml/min/1.73m2). Results We analysed a total of 4446 subjects; 1598 were on SGLT2is. There was a significant reduction in CKD progression (hazard ratio [HR] 0.60; 95% confidence interval [CI] 0.49–0.74) with SGLT2is. The HR for eGFR ≥ 45 ml/min/1.73m2 and eGFR 15–44ml/min/1.73m2 was 0.60 (95% CI 0.47–0.76) and 0.43 (95% CI 0.23–0.66) respectively. There was also a reduction in risk for developing ESKD for the entire cohort (HR 0.33; 95% CI 0.17–0.65) and eGFR 15–44ml/min/1.73m2 (HR 0.24; 95% CI 0.09–0.66). Compared to canagliflozin and dapagliflozin, empagliflozin showed a sustained risk reduction of renal outcomes across stages 1–4 CKD. Conclusions This real-world study demonstrates the benefits of SGLT2is on CKD progression and ESKD. The effect is more pronounced in moderate to advanced CKD patients.
BackgroundFor patients unable to receive heparin anticoagulation during haemodialysis, saline flushes to reduce circuit clotting are often the norm. Regional citrate anticoagulation (RCA) although effective is not used by many centres including in Singapore. We wanted to demonstrate the superiority and safety of a simple regional citrate anticoagulation regime, compared to saline flushes, for heparin-free low flux haemodialysis.MethodsThis is a prospective, open label, cross over study on 25 sequential haemodialysis sessions for inpatients receiving heparin-free haemodialysis. Patients were allocated either to regional citrate anticoagulation or standard heparin free haemodialysis and subsequently cross over to the alternate method. RCA was carried out using a protocol derived from previous studies. Assessment of anticoagulation was performed using visual inspection of clot formation in dialysis circuits and post-filter ionized calcium (iCa2+) using point-of-care Ionized calcium device at stipulated intervals. Intravenous Calcium gluconate replacement was given to patients receiving citrate adjusting the rate according to pre-filter iCa2+. Laboratory analyses of electrolytes were also assessed at the start and end of the RCA sessions.ResultsThere were no clots in the RCA arm, with 79% (n = 19) in the saline flush arm having some clot, including 1 clotted circuit. Post-filter iCa2+ at various time points were within acceptable range.Electrolyte readings in the RCA group were all within normal limits except for 4 cases of total Calcium:iCa2+ ratio > 2.5.ConclusionRCA is confirmed to be superior to saline flushes for circuit patency. We have a simple and safe protocol that can be followed for low flux haemodialysis.The study was approved by Singapore National Health Group domain-specific ethnical committee. NHG DSRB reference number 2014/01037.Trial registrationTrial registration number: ISRCTN69952745 (registration date 8/11/17).
This is one of the first reports of TDC insertion by nephrologists from SEA. Our outcomes compare favourably with those reported in the literature.
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