Impact of Sodium-Glucose Co-transporter 2 Inhibitors on Cardiovascular System and Anemia in Non-diabetic Chronic Kidney Disease Patients. A Randomized-Controlled Clinical Trial
Phase: PHASE3
Conditions: Chronic Kidney Disease, Anemia, Cardiovascular Calcification
Sponsor: Mansoura University

Official Study Title: 
Impact of Sodium-Glucose Co-transporter 2 
inhibitors on Cardiovascular System and Anemia in 
Non-diabetic Chronic Kidney Disease Patients. A 
Randomized-Controlled Clinical Trial  
 
ClinicalTrials.gov Identifier (NCT Number): 
Pending 
 
Document Type: 
[Study Protocol / Statistical Analysis Plan] 
 
Document Date: 
[April 24, 2022] 
 
Sponsor/Collaborator: 
Mansoura Urology and Nephrology Center, Mansoura University, Egypt 
 
Principal Investigator: 
Dr. Mostafa Gamal, MD, PhD 
 
 

Introduction 
Chronic kidney disease (CKD) affects approximately 10% of the adult population 
worldwide (1). The most common causes of CKD are diabetes, hypertension, and chronic 
glomerulonephritis (2). Treatment for CKD includes angiotensin converting enzyme 
inhibitor (ACE-I) / angiotensin II receptor blockers (ARBs), lipid and blood pressure 
(BP) control (3). 
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a newly approved class of 
oral anti-diabetic agents that increase the urinary excretion of glucose, thereby lower 
blood glucose levels, weight, and blood pressure (4). 
There is growing evidence indicating that SGLT2 inhibition is reno-protective. 
This effect is thought to be achieved partly by mechanisms independent of lowering 
blood glucose levels (5), such as reduced intra-glomerular pressure through an enhanced 
tubule-glomerular feedback mechanism (6-7), reduced glucose and sodium transport over 
the proximal tubular cells (8), increased natriuresis (9) and reduced systemic BP (10-11).  
A recent clinical trial (DAPA-CKD) showed that SGLT2i treatment reduced the risk 
of worsening kidney function or death from cardiovascular or kidney disease in patients 
with chronic kidney disease with and without type 2 diabetes (12).  
Also, there are data suggesting SGLT2i acts by inhibiting hepcidin, which will 
increase iron bioavailability and red blood cell production (13). Another mechanism is 
suggested via inducing medullary hypoxia which by turn increases the level of 
hypoxia inducible factor (HIF) and increase erythropoietin production (14). These 
effects on erythropoiesis suggest that the use of SGLT2i reduces the occurrence of 
anemia. The post-hoc analysis of the CREDENCE trial found that the risk of anemia or 
the risk of starting anemia treatment in the anemia group of patients with type 2 diabetes 
and chronic kidney disease was significantly lower than that of the placebo group (15). 
According to the exploratory analysis of EMPA-REG test data, anemia improvement 
during SGLT2i treatment was closely related to beneficial cardiovascular outcomes (16).  
Dapagliflozin, as a member of SGLT2i family, showed a beneficial effect on 
cardiovascular outcome (17, 18). As shown in many other trials, Other SGLT2 
inhibitors have shown favorable cardiovascular effects, including a reduction in the risk 

of hospitalization for heart failure, predominantly in patients with type 2 diabetes and 
established cardiovascular disease (19-21). 
SGLT2 inhibition affects 
visceral 
adiposity, 
glycemic 
control, 
hyperinsulinemia, blood pressure, arterial stiffness, and albuminuria (22). Two 
mechanisms have been proposed as major drivers for beneficial cardiovascular 
outcome: the diuretic effect associated with SGLT2 inhibition with subsequent 
hemodynamic unloading of the left ventricle (23) and a shift in cardiac metabolism 
secondary to increased ketogenesis (24, 25). 
 
 

Aim of the work 
This study aims to: 
1. Assess SGT2i role in delaying the progression of ongoing chronic kidney 
disease. 
2. Investigate SGLT2i impact on anemia improvement among non-diabetic CKD 
patients. 
3. Study the impact of SGLT2i on cardiovascular system in these patients. 
 
 

Research questions 
The main research question is: Does use of SGLT2i will show superiority over 
conventional lines of treatment of chronic kidney disease as regard to efficacy and safety? 
Does the use of SGLT2i carry beneficial effect on anemia improvement among 
these patients? 
Does the use of SGLT2i improve cardiac outcome in non-diabetic CKD patients? 
 
 

Rationale and justification 
Dapagliflozin which was originally developed to control blood glucose level in 
patients with diabetes has recently been shown to have beneficial effects on both the heart 
and kidney. 
 Importantly, a large clinical trial has shown dapagliflozin reduced kidney 
problems. From the way we think the pills work, there is good reason to believe this new 
medication could benefit people who have kidney disease even they are not diabetic. 
To date, there hasn’t been a trial that studied the effect of dapagliflozin in terms 
of anemia improvement only on non-diabetic CKD.  
 
 

Objectives 
The main objective of this study is to: 
▪ Compare use of SGLT2i versus placebo and standard care in regression of chronic kidney 
disease in non-diabetic CKD patients.  
▪ Study the effect of SGLT2i in decreasing the risk of anemia and improving anemia in 
non-diabetic CKD patients. 
▪ Study the impact of SGLT2i regarding cardiovascular system. 
 
 

Hypothesis 
Additional therapies to slow kidney function decline are highly desired. The 
DAPA-CKD trial demonstrated that the sodium glucose co-transporter 2 inhibitor 
dapagliflozin significantly reduced the risk of kidney failure and prolonged survival in 
participants with chronic kidney disease with and without type 2 diabetes.   
 
 

Patients and methods 
Study sitting: Urology and Nephrology Center, Mansoura University. 
Study design and sample size: 
• Sample size: was calculated based on previous research by (DAPA-CKD) by 
(Heerspink et al., 2020) using G. power program with α error 0.05 and power 80% and 
it was equal to approximately 98 patients. 
Type of the study: Randomized controlled trial. 
Patients’ enrollment: 100 patients with non-diabetic CKD with an estimated glomerular 
filtration rate (eGFR) of 20-75 ml/min/1.73m2 will be randomized into 2 equal groups: 
• Study group: 50 patients will receive SGLT2i as add on drug, Dapagliflozin 10 mg 
will be used once daily with or without food. 
• Control group: 50 patients will receive placebo beside the conventional medications. 
All patients will be followed-up for 12 months and their results will be interpreted.   
Inclusion criteria: 
1. 
Non-diabetic CKD patients aged more than 18 years. 
2. 
Patient with eGFR > 20 ml/min/1.73m2 by 2021 CKD-EPI creatinine equation  
Exclusion criteria: 
1. eGFR < 20 ml/min per 1.73 m2. 
2. Medical history of chronic disease (diabetes mellitus, chronic liver disease, bladder cancer, 
severe respiratory distress). 
3. Evidence of urinary obstruction of difficulty in voiding at screening. 
4. Receiving high dose diuretics or combined ACEI and ARB. 
5. History of recurrent urinary tract infection. 

6. Active infection including TB and HIV. 
7. Current or previous organ transplantation or expected to get a kidney transplant within 12 
months. 
8. Patients who are on SGLT2i for more than the preceding 3 months.  
 
Study design: 
Study Protocol: 
 
• Patients included in the study will be treated with dapagliflozin initiated at a 
single daily morning dosage of 10 mg/day. 
 
Methods: 
The following data will be collected and evaluated for all patients: 
I-Baseline investigations:  
➢ Patients of both groups will be subjected to full history taking including duration of 
CKD and drug history and routine clinical examination. 
➢ Ankle/brachial pressure index (ABPI) to assess peripheral vascular disease. 
➢ Laboratory investigations: 
1) Serum creatinine, Creatinine clearance. 
2) Urine analysis. 
3) 24-hour urine protein and/or spot urine protein/creatinine ratio.  
4) Random blood glucose. 
5) Lipid profile 
6) Iron profile tests: 

▪ Hemoglobin 
▪ Mean corpuscular volume (MCV) and Hematocrit (Hct). 
▪ Serum ferritin 
▪ Transferrin saturation (TSAT) 
▪ Serum hepcidin level 
▪ Serum erythropoietin level. 
7) B-type natriuretic peptide (BNP) level. 
➢ Cardiovascular investigatory tools:  
▪  Electrocardiography (ECG).  
▪ Echocardiography to assess myocardial function.  
➢ Radiological investigations: 
▪ Agatston score using CT scan: for assessment of coronary calcification.  
1. II-Post-intervention investigations:  
All patients will be evaluated every visit (every 3 months) regarding: 
➢ Regular measurement of blood pressure each visit. 
➢ Ankle/brachial pressure index. 
➢ Laboratory investigations: 
1) Serum creatinine, creatinine clearance. 
2) Urine analysis. 
3) 24-hour urine protein and/or spot urine protein/creatinine ratio.  
4) Fasting blood glucose. 
5) Lipid profile. 

6) Iron profile (Hemoglobin, MCV, hematocrit, ferritin, TSAT,) 
All patients will be evaluated at 12 months regarding: 
➢ Ankle/brachial pressure index. 
➢ Laboratory investigations: 
1) Serum creatinine, Creatinine clearance. 
2) 24-hour urine protein and/or spot urine protein/creatinine ratio. 
3) Urine analysis.  
4) Fasting blood glucose. 
5) Lipid profile. 
6) Iron profile tests: 
▪ Hemoglobin 
▪ Mean corpuscular volume (MCV) and Hematocrit (Hct). 
▪ Serum ferritin 
▪ Transferrin saturation (TSAT) 
▪ Serum hepcidin level 
▪ Serum erythropoietin level. 
➢ Cardiovascular investigatory tools:  
▪  Electrocardiography (ECG).  
▪ Echocardiography to assess myocardial function.  
➢ Radiological investigations: 
▪ Agatston score using CT scan: for assessment of coronary calcification.  
 
 

Outcomes: 
 
Primary outcome measures: 
• Time to the first occurrence of any of the components of the composite: 
≥50% sustained decline in eGFR, reaching end-stage kidney disease.   
[Time Frame: 12 months] 
 
Secondary outcome measures: 
• Effect of Dapagliflozin on eGFR. 
• Effect of Dapagliflozin on anemia & erythropoietin level. 
• Effect of Dapagliflozin on myocardial function and coronary 
calcifications.  
• Safety of Dapagliflozin regarding the number of hypoglycemia episodes 
between groups and serious adverse events. 
 
 

Statistical Analysis: 
Qualitative data will be displayed in cross tabulations, and quantitative data 
will be described in terms of arithmetic mean ± SD. Bivariate techniques will be 
used for initial evaluation of contrasts. Thus, the chi-square and Fisher's exact tests 
will be used for comparisons of frequencies of qualitative variables; the Mann-
Whitney test and the unpaired t-test will be used for comparisons of means of two 
quantitative variables. A p-value ≤0.05 is considered significant. Patient survival 
rates will be assessed using the Kaplan-Meier method. All analyses will be carried 
out using the computer package SPSS for windows, release 21 SPSS Inc. Chicago, 
III, USA. 
Administrative design 
All the patients provided written informed consent before study entry and the 
approval was obtained from institutional review board (MS.22.04.1973) in Faculty of 
Medicine, Mansoura University. There is no funding.  
 
 

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