Dapagliflozin 透過調控自噬反應抑制腎結石形成

劉展榮^1,2、何冠達³、黃鶴翔^1,2、盧則宏^1,2、謝幸㚬⁴、張毓珊⁵、賴嘉鎮^4*、蔡曜聲^3,6,7*

¹成大醫院泌尿部、²成大醫學院泌尿學科、³成功大學醫學院基礎醫學研究所、⁴成大醫學院臨床藥學與藥物科技研究所、⁵奇美醫院急診部、⁶成功大學醫學院臨床醫學研究所、⁷成大醫院臨床醫學中心

*通訊作者：賴嘉鎮（edward_lai@mail.ncku.edu.tw）、蔡曜聲（yaustsai@mail.ncku.edu.tw）

Dapagliflozin inhibits kidney stones via modulating autophagy

Chan-Jung Liu^1,2, Kaun-Ta Ho³, Ho-Shiang Huang^1,2, Ze-Hong Lu^1,2, Miyuki Hsing-Chun Hsieh⁴, Yu-Shan Chang⁵, Edward Chia-Cheng Lai^4*, Yau-Sheng Tsai^3,6,7*

Affiliations:

1. Department of Urology, National Cheng Kung University Hospital, Tainan, Taiwan

2. Department of Urology, College of Medicine, National Cheng Kung University, Tainan, Taiwan 704302; dragon2043@hotmail.com (C.-J.L.); hshuang54@gmail.com (H.-S.H.)

3. Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan 704302; percytrynd@gmail.com (K.-T.H.)

4. School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan 704302; s1234567y@gmail.com (M.H.-C.H.); edward_lai@mail.ncku.edu.tw (E.C.-C.L.)

5. Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan (Y.-S.C.)

6. Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan 704302

7. Center for Clinical Medicine Research, National Cheng Kung University Hospital, Tainan, Taiwan 704302; yaustsai@mail.ncku.edu.tw (Y.-S.T.)

*Correspondence: Edward Chia-Cheng Lai and Yau-Sheng Tsai equally contributed to this work. Edward Chia-Cheng Lai, School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan 704302. E-mail: edward_lai@mail.ncku.edu.tw; Yau-Sheng Tsai, Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan 704302. E-mail: yaustsai@mail.ncku.edu.tw

Purpose:

Recent studies suggest sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce kidney stone risk in diabetes mellitus (DM), but the mechanism is unclear. This study aims to study if dapagliflozin (DAPA), a SGLT2i, can inhibit calcium oxalate (CaOx) stones and whether autophagy is the mechanism.

Materials and methods

        First, we conducted a cohort study that employed Taiwan’s National Health Insurance Research Database (NHIRD), approved by IRB: A-ER-109-567. We included type 2 DM over 40 who started SGLT2i or dipeptidyl peptidase-4 inhibitor (DPP4i) from 2016 to 2020, excluding those prescribed both drugs on the same date or with end-stage renal disease. Second, we used male C57BL mice, divided into control, glyoxylate (GOX), and GOX + DAPA. GOX was to induce CaOx kidney stone formation. DAPA (10 mg/kg/day) was orally given for six days. Intraperitoneal injection of GOX (100 mg/kg/day) was started from the second day for five days. On day 7, all mice were sacrificed.

Results

        First, we used nationwide cohort data to compare kidney stone risk in DM using SGLT2i versus DPP4i. We identified 84,749 SGLT2i and 437,325 DPP4i initiators without a history of kidney stone. The incidence rate ratio favored SGLT2i at 0.86 (95% CI, 0.82-0.90) (Fig. A).

Second, in GOX-induced kidney stone mice, GOX treatment increased urine Ox and reduced urine citrate and Mg, increasing CaOx stone risk (Fig. B~F). DAPA reduced urine Ox and increased urine citrate, decreasing CaOx supersaturation, reversing acidified urine pH, and inhibiting GOX-induced kidney stone, as evidenced by polarized microscopy (Fig. G).

Finally, we examined DAPA’s effect on stone-mediated autophagy. GOX significantly upregulated LC3B-II/I ratio, and p62, indicating that kidney stones promoted autophagosome synthesis but impaired autophagic flux (Fig. H). DAPA downregulated LC3B-II/I ratio, and p62, suggesting that DAPA improves stone-induced impairment in autophagic flux. To confirm autophagy in kidneys with CaOx stones, we used immunofluorescent staining for LC3B (red, autophagosome), NLRP3 (green, inflammasome), and SGLT2 (white, indicator of cortex). GOX increased NLRP3 in the medulla, reversed by DAPA. GOX increased LC3B puncta, near NLRP3-positive tubules (Fig. I). This suggested GOX impairs autophagic flux linked to CaOx stones, resolved by DAPA.

Conclusions

SGLT2i inhibits CaOx stones via resolving impaired autophagic flux.