2) Christos Argyropoulos MD, PhD @ChristosArgyrop is Division Chief, Nephrology @UNMHSC.#FOAMed #nephtwitter #cardiotwitter @MedTweetorials @NephUCommunity @ISNkidneycare @KidneyDiseaseFm pic.twitter.com/UHbSuw0sNs
— @CKD_ce (@ckd_ce) May 24, 2023
4) We'll be building on the foundations of:
— @CKD_ce (@ckd_ce) May 24, 2023
1. @edgarvlermamd re kidney protective mechanisms of action #MOA of (nonsteroidal) #MRAshttps://t.co/XGTAB7UoJq
2. screening & risk stratification using #microalbuminuria in #T2D with #CKD by @christosargyrophttps://t.co/x1nKRaFm4V
6) If you answered #4, you are correct!
— @CKD_ce (@ckd_ce) May 24, 2023
We have known since the early 1940s, that mineralocorticoid excess can cause damage to the heart, kidney & vessels. The journey to nonsteroidal #MRA was long:
🔓 https://t.co/4J5rfzyp8d
🔓 https://t.co/i6pHfHZKP7
🔓 https://t.co/pMBpL18Ed2 pic.twitter.com/3DAGovoyQc
8) In patients #T2D a proxy of identifying pts at risk for advancing #CKD, #ESKD, & #cardiovascular morbidity/mortality is the level of #eGFR & #microalbuminuria (#UACR). The #RCTs #FIDELIODKD & #FIGARODKDnonsteroidal #MRA were based on this concept
— @CKD_ce (@ckd_ce) May 24, 2023
🔓 https://t.co/B8J9hRtd5j
10) At a very hi level, the nonsteroidal #MRAsmirrored what we do (or should be doing) in practice: improve the health and protect the kidney, heart, and blood vessels of pts w/ #CKD & #T2D. The design & recruitment in #FIDELIODKD makes this obvious:
— @CKD_ce (@ckd_ce) May 24, 2023
🔓 https://t.co/GeIhtLS7h7 pic.twitter.com/ABKmDwsWet
12) #FIDELIODKD in a nutshell:
— @CKD_ce (@ckd_ce) May 24, 2023
▶️ ↓ ~20% in kidney outcomes (#ESKD, sustained drop in #eGFR > 40% or kidney death)
▶️ ↓ ~14% in composite CV outcome
This is a practice changing RCT: in pts w/#T2D & #CKD w/ ↑ #UACR finerenone, ↓ heart & kidney risk
🔓 https://t.co/kSVp01OSCz pic.twitter.com/SrxTQ3PWvW
14) Adverse events were similar between nonsteroidal #MRA and placebo except for
— @CKD_ce (@ckd_ce) May 24, 2023
▶️#HyperK (hyperkalemia) related adverse events, whose risk factors, clinical significance and management we will consider at length later in this #tweetorial
🆘#AKI (Acute Kidney Injury) did NOT ↑ pic.twitter.com/hi8UGTCkLY
16) Based on these trial results, #finerenone is currently indicated to ↓ the risk of
— @CKD_ce (@ckd_ce) May 24, 2023
1. sustained #eGFR decline,
2. #ESKD,
3. #cardiovascular death, non-fatal #MI, and #HHF
in adult patients with #CKD associated with #T2Dhttps://t.co/8QddD0hCsW pic.twitter.com/56NUFIMRh8
18) #FIDELITY reassured that the safety, cardiovascular and kidney benefits of #finerenone were sustained across a wide spectrum of #CKD in #T2D with a precision afforded by the large #meta_analysis sample size
— @CKD_ce (@ckd_ce) May 24, 2023
🔓 https://t.co/CJCUKz6erN pic.twitter.com/Lw8vjaPTEO
20) As I have stated previously read the #FIDELITY supplements to see that #finerenone was tested in the pts we see in our clinics, and it works irrespective of any other agents e.g. #flozins/#GLP1RA used or any other patient characteristics.https://t.co/V5MbP6dDnN
— @CKD_ce (@ckd_ce) May 24, 2023
22) Return TOMORROW to join me on that quest—as well as your OWN quest to 0.75hr 🆓CE/CME!#FOAMed @MedTweetorials #nephtwitter @GarySingerMD @ISNeducation @anna_burgner @Gawad_Nephro @DiMiRenalMD @swissnephro @drdschwartzmd @msocoMD @SayaliBThakare @sriperumbuduris @KRUKPhD
— @CKD_ce (@ckd_ce) May 24, 2023
24) As promised: a deep dive into #HyperK:
— @CKD_ce (@ckd_ce) May 25, 2023
🛑When using nonsteroidal #MRAs on top of max tolerated doses of #ACEinhibitors or #ARBs, especially in pts with lower #eGFR, HyperK may develop (though at lower rates than steroidal #MRAs).
💬Further FACTS about this side effect: pic.twitter.com/koNDMe6dnT
25b) ▶️ Discontinuations of therapy due to #HyperK was infrequent in #FIDELITY(0.66/100 PYs for #MRA vs 0.22 for placebo & no fatal HyperK occurred pic.twitter.com/5LBXQis25q
— @CKD_ce (@ckd_ce) May 25, 2023
27) To sum up:
— @CKD_ce (@ckd_ce) May 25, 2023
➡️#HyperK may occur w/ (↑risk) or w/out MRA under ACEi/ARB in #CKD due to #ENACchannel
🔓 https://t.co/z65jk4PkeH
➡️Continued use of MRAs is required for cardiovascular & kidney benefit
➡️Management of HyperK allows the safe use of MRAs, but how can we do this? pic.twitter.com/wtC84bD0lX
29) Use the #FIDELIODKD protocol to build your #HyperK strategy:
— @CKD_ce (@ckd_ce) May 25, 2023
✔️K & maintain #MRA dose as long as K <5.5 (start when K<4.8)
🔎alternative causes that may have led to ⬆️ K (> 5.5)
Temporarily 🛑 #finerenone for 72hr & restart at lower dose if K ≤ 5
🔓 https://t.co/N1ERNMgnoh pic.twitter.com/aIN8vWpgsd
31) If you answered “Both” you are correct!
— @CKD_ce (@ckd_ce) May 25, 2023
(and if you answered None, then I am doing a poor job detailing the evidence, because ↑#UACR despite maximum doses of #ACEi/ARB in pts with #T2D and #CKD calls for additional therapies e.g. nonsteroidal #MRA).
Let's see why!
33) BP in #finerenone trials:
— @CKD_ce (@ckd_ce) May 25, 2023
🔎 In #FIDELITY SBP at 4 mos was –3.2 ± 15.0 mmHg w/ #finerenone v +0.5 ± 14.6 mmHg w/ placebo
🔎 #ABPM ↓ was larger ( –8.3 mmHg, seen in in ARTS-DN) than office SBP & > 2x those of #SGLT2i
🔓 https://t.co/i5oL87FC9I
🔓 https://t.co/dhvxXnWwS5 pic.twitter.com/vBNajNWGXc
35) The last few #tweets will address the big question : #SGLT2i , #MRA or both in patients with #T2D , #CKD and residual albuminuria despite maximum doses of #ACEi or #ARB ? pic.twitter.com/i4UD4HKNla
— @CKD_ce (@ckd_ce) May 25, 2023
37) Clinicians should ponder the questions:
— @CKD_ce (@ckd_ce) May 25, 2023
1. Are #SGLT2i more potent than nonsteroidal #MRA (or vice versa)?
2. Does 1 interfere w/ the other?
Eyeballing HR (30-40% ↓ in #flozin RCTs) or network #meta_analysis may suggest that #SGLT2i > #MRA yet …
🔓 https://t.co/nKwYzMkexZ pic.twitter.com/TeyH8DgUOO
39) 👉Effects of #finerenone similar in #FIDELIODKD pts receiving #SGLT2i v those who didn’t
— @CKD_ce (@ckd_ce) May 25, 2023
🔓 https://t.co/W6UjTyHIu5
👉Effects of #SGLT2i similar in those receiving steroidal #MRA in DAPA-CKD v those who didn’t
🔓 https://t.co/cpCtM4vu0A
👉 i.e. no evidence of interference pic.twitter.com/DWcPkmNw8X
41) Until #CONFIDENCE has resulted, clinicians should consider treating residual albuminuria in pts on #SGLT2i with a nonsteroidal #MRA & vice versa while taking a holistic management approach for #CKD in #T2D as in @goKDIGO & @AmDiabetesAssn
— @CKD_ce (@ckd_ce) May 25, 2023
🔓 https://t.co/nW2evUuYid pic.twitter.com/uy72TuTNaq
43) And CONGRATULATIONS! You just earned 0.75hr 🆓CE/#CME!–#physicians #physicianassociate #pharmacists #nurse #nursepractitioner 🇺🇸🇪🇺 🇬🇧🇨🇦. Claim your certificate NOW at https://t.co/on4HqA5V6y. @ckd_ce and @ChristosArgyrop THANK YOU for joining us! FOLLOW US!
— @CKD_ce (@ckd_ce) May 25, 2023