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However&#44; we now understand that it plays an important role in glucose homeostasis in two ways&#58; <span class="elsevierStyleItalic">1&#41;</span> gluconeogenesis&#44; and <span class="elsevierStyleItalic">2&#41;</span> glomerular filtration and reabsorption of glucose in the proximal convoluted tubules&#46;</p><p class="elsevierStylePara">With a better understanding of the renal mechanisms responsible for glucose homeostasis and the ability to manipulate that system&#44; the kidney has become a key component in the treatment of hyperglycaemia&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Filtration and the reabsorption of glucose</span></p><p class="elsevierStylePara">For a healthy adult&#44; approximately 180g of glucose is filtered by the glomerulus every day&#46;<span class="elsevierStyleSup">5 </span>Under normal circumstances&#44; almost all of this glucose is reabsorbed with less than 1&#37; being excreted in the urine&#46;<span class="elsevierStyleSup">6</span> Glucose reabsorption in the tubules is a multi-step process involving several transport mechanisms&#46; Glucose is filtered through the tubule and then transported via the tubular epithelial cells through the basolateral membrane into the peritubular capillary&#46; Under optimal conditions&#44; when tubular glucose load is approximately 120mg&#47;min or less&#44; there is no glucose loss in urine&#46; However&#44; when the glucose load exceeds approximately 220mg&#47;min &#40;glucose threshold&#41;&#44; glucose starts to appear in the urine&#46;</p><p class="elsevierStylePara">The blood glucose level required to provide such a tubular load covers a range of values in humans&#46; A study of this process reported that the blood glucose concentration required to exceed the tubular glucose threshold ranged between 130 and 300mg&#47;dl&#46;<span class="elsevierStyleSup">7</span> In addition&#44; the study found a relationship between age and increased threshold levels&#46;</p><p class="elsevierStylePara">90&#37; of filtered glucose is reabsorbed by the high absorption capacity of SGLT2 transporter in the convoluted segment of the proximal tubule&#44; and the remaining 10&#37; of filtered glucose is reabsorbed by the SGLT1 transporter in the straight segment of the descending proximal tubule&#46;<span class="elsevierStyleSup">2</span> As a result&#44; no glucose appears in the urine&#46;</p><p class="elsevierStylePara">The maximum renal capacity for tubular reabsorption &#40;Tm&#41; of glucose is greater in animal models with type 1 and type 2 diabetes&#46;<span class="elsevierStyleSup">8</span> In people with type 1 diabetes&#44; Mogensen et al&#46;<span class="elsevierStyleSup">9</span> showed that the glucose Tm is increased&#46; Conflicting results have been reported in patients with type 2 diabetes&#46;</p><p class="elsevierStylePara">Clinically&#44; the most common cause of glycosuria is diabetes&#46; Patients do not excrete glucose in the urine until the concentration of blood glucose is over 180mg&#47;dl&#44; which does not normally occur in people without diabetes&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Role of the SGLT2 transporter </span></p><p class="elsevierStylePara">The first step in the reabsorption of urine glucose involves the transport of glucose from the tubules to peritubular capillaries via tubular epithelial cells&#46;<span class="elsevierStyleSup">10</span> This is accomplished with the family of sodium-glucose cotransporters &#40;SGLT&#41;&#44; see Figure 1&#46; The SGLTs include a variety of membrane proteins that act on the transport of glucose&#44; amino acids&#44; vitamins&#44; ions and osmolytes across the brush border membrane of the renal proximal tubules and the intestinal epithelium&#46;<span class="elsevierStyleSup">11</span> SGLT1 is a low capacity and high affinity carrier&#46; It is found mainly in the gastrointestinal tract&#44; but can also be found in the S3 segment of the renal proximal tubule&#46; Although SGLT1 is the key transporter for glucose absorption in the gastrointestinal tract&#44; its impact on the kidney is less important&#59; representing about 10&#37; of glucose reabsorption&#46;</p><p class="elsevierStylePara">This has been of some pharmacological interest because blocking this transporter theoretically reduces the gastrointestinal absorption of glucose and may provide a method for inducing weight loss or reducing postprandial hyperglycaemia&#46;</p><p class="elsevierStylePara">By contrast&#44; SGLT2 transporter has a high capacity and low affinity&#44; and is found mainly in the kidney&#46; Table 1 compares the SGLT1 and SGLT2 transporters&#46;</p><p class="elsevierStylePara">A third member of this family&#44; SGLT3&#44; is widely found in skeletal muscle and the nervous system&#46; SGLT3 is not believed to be a glucose transporter&#44; but acts as a sensor&#46;<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">Although other members of this family have been identified &#40;SGLT4&#44; SGLT5 and SGLT6&#41;&#44; their role in humans is not known at this time &#40;Table 2&#41;&#46; The most prevalent and functionally most important transporter in the kidney is SGLT2&#46; It is responsible for 90&#37; of glucose reabsorption in the kidney&#44; and has become the subject of much interest in the diabetes field&#46;</p><p class="elsevierStylePara">This transporter is found in a relatively high proportion in the initial segment of the proximal tubule &#40;S1&#41;&#46; SGLT2 transports glucose by using the energy gradient of sodium reabsorption in the tubular filtration&#46; This process is called secondary active transport and is driven by the electrochemical gradient of sodium in the tubular filtration&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RENAL GLYCOSURIA&#58; SGLT2 TRANSPORTER INHIBITION MODEL</span></p><p class="elsevierStylePara">Renal glycosuria is a genetic condition where the effects of the inhibition of SGLT2 transporter can be observed&#46; Patients with this condition are asymptomatic&#44; even though in most cases they have a SLC5A2 gene mutation &#40;solute carrier family 5A&#41;&#44; responsible for encoding SGLT2 transporter protein&#46; Autosomal dominant and recessive inheritance patterns have been reported&#46; As a result of this mutation&#44; patients with renal glycosuria excrete in their urine more than 100g of glucose in 24 hours&#46;</p><p class="elsevierStylePara">Santer et al&#46;<span class="elsevierStyleSup">13</span> conducted a genetic study on 23 families diagnosed with renal glycosuria and found 21 different mutations of the SLC5A2 gene&#46; Fourteen out of the 21 families were homozygous and had glycosuria between 15 and 200g&#47;day&#46; Heterozygotes typically had glycosuria of under 4&#46;4g&#47;day&#44; although some did not&#46;</p><p class="elsevierStylePara">Two families diagnosed with renal glycosuria did not have the SLC5A gene mutation&#44; but may have had mutations of the genes encoding GLUT2 &#40;type 2 glucose transporter&#41;&#44; HNF-1&#945; &#40;hepatic nuclear factor 1 alpha&#41; which regulates the transcription of SGLT2 or genes related with SGLT1 or SGLT3&#46;</p><p class="elsevierStylePara">Except for glycosuria&#44; there were no other associated diseases&#46; Plasma glucose was high or low&#44; and blood volume remained essentially normal due to sodium reabsorption via other transporter channels&#46; Renal and bladder function was normal&#44; and this group of patients had no increased incidence of diabetes&#44; kidney disease or urinary tract infections&#44; compared with the general population&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">Figure 2 schematically shows the reabsorption of glucose in normal individuals and patients with renal glycosuria&#46; As mentioned previously&#44; the maximum renal capacity of tubular reabsorption &#40;Tm&#41; for glucose is variable&#44; although for physiological studies &#40;theoretical&#44; continuous black line&#41; it is about 198mg&#47;dl &#40;11mmol&#47;l&#41;&#46; The glucose Tm usually observed is below this figure &#40;broken black line&#41;&#44; and is saturated with glucose concentrations near 180mg&#47;dl &#40;10mmol&#47;l<span class="elsevierStyleSup">15</span>&#41;&#46;</p><p class="elsevierStylePara">Renal glycosuria can be classified into two types&#46;<span class="elsevierStyleSup">13</span> Type A has a glucose Tm lower than in normal subjects &#40;blue line&#41;&#46; These patients have decreased SGLT2 transporter activity as well as more significant glycosuria&#46;</p><p class="elsevierStylePara">In type B renal glycosuria&#44; the SGLT2 transporter has no affinity for glucose&#44; resulting in a decrease in the reabsorption rate of glucose&#44; but a normal glucose Tm &#40;green line&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">TYPE 2 <span class="elsevierStyleItalic">DIABETES MELLITUS</span> AND THE SGLT2 TRANSPORTER </span></p><p class="elsevierStylePara">Type 2 <span class="elsevierStyleItalic">diabetes mellitus</span> is associated with increased expression and activity of SGLT2&#46;</p><p class="elsevierStylePara">In a study<span class="elsevierStyleSup">16</span> of the SGLT2 transporter&#44; human exfoliated proximal tubular epithelial cells &#40;HEPTC&#41; were used&#44; which were obtained from urine samples&#46; HEPTC were isolated from healthy individuals and diabetic patients&#44; and were cultured in a hyperglycaemic medium&#46;</p><p class="elsevierStylePara">As shown in Figure 3&#44; the HEPTC of diabetic patients showed a statistically significant higher expression of SGLT2 and GLUT2 compared with non-diabetic individuals&#46; They also determined the renal glucose uptake using methyl-&#945;-D-&#91;U<span class="elsevierStyleSup">14</span>C&#93;-glucopyranoside &#40;AMG&#41;&#44; which is an analogue of glucose&#46; More glucose uptake was also observed in diabetes patients&#8217; HEPTC than in individuals without diabetes&#46;</p><p class="elsevierStylePara">These findings prove that the renal system noticeably contributes to the body&#39;s energy balance by regulating glucose uptake&#44; and that diabetic patients appear to be poorly adapted to this mechanism&#46; In diabetes&#44; glucose reabsorption may be increased in absolute terms by an increase of glucose Tm&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">SGLT2 TRANSPORTER INHIBITORS FOR THE TREATMENT OF TYPE 2 <span class="elsevierStyleItalic">DIABETES MELLITUS</span></span></p><p class="elsevierStylePara">In 1835&#44; French chemists isolated a substance called phlorizin from the roots of apple trees&#46; Although it was believed that phlorizin was a compound for treating fever&#44; infectious diseases and malaria&#44; it was not until 50 years after its discovery that it was found that high doses of phlorizin caused glycosuria&#46;<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">For several decades&#44; phlorizin was used in the assessment of renal physiology&#46; Then in 1970&#44; it was discovered that glycosuria could be caused by phlorizin inhibiting an active transport system for tubular reabsorption of glucose&#46; Between 1980 and 1990&#44; the SGLT2 transporter was identified&#44; and the inhibition of this transporter began to be profiled as a treatment for type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#46; Phlorizin was therefore the first known SGLT2 inhibitor&#46;</p><p class="elsevierStylePara">However&#44; phlorizin could not be used as a treatment for type 2 <span class="elsevierStyleItalic">diabetes mellitus</span> for several reasons&#46; Firstly&#44; because intestinal absorption is very poor and&#44; secondly&#44; because it does not just inhibit SGLT2&#44; it is also capable of inhibiting SGLT1&#44; causing osmotic diarrhoea in most cases&#46;</p><p class="elsevierStylePara">SGLT2 inhibition can reduce plasma glucose levels by reducing the glucose Tm&#44; resulting in increased urinary excretion of glucose&#46;</p><p class="elsevierStylePara">In animals without diabetes&#44; inhibition of SGLT2 has no effect on plasma glucose&#44; because hepatic glucose production is increased to compensate for glycosuria&#46; However&#44; in diabetic animals&#44; administration of SGLT2 inhibitors produces dose-dependent glycosuria and a significant reduction in plasma glucose&#46;</p><p class="elsevierStylePara">SGLT2 inhibition essentially resets the maladaptive diabetic kidney by reducing the affinity of the transporter and increasing glycosuria&#44; which decreases blood glucose and&#44; therefore&#44; glucotoxicity&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">Recently&#44; Phlorizin analogues selective for SGLT2 with better intestinal absorption have been developed&#46; Table 3 shows some drugs in this group&#44; including dapagliflozin and canagliflozin&#44; which are currently in phase III clinical trials&#46;</p><p class="elsevierStylePara">In addition&#44; one laboratory is currently in phase I clinical trials<span class="elsevierStyleSup">19 </span>with a molecule called ISIS-388626 to reduce expression of SGLT2&#46; This compound is an oligonucleotide that decreases transcription of the gene encoding the SGLT2 transporter&#46; In murine and canine models&#44; treatment with ISIS-388626 is highly selective&#44; as it reduces the mRNA &#40;messenger ribonucleic acid&#41; of SGLT2 by 80&#37; without modifying SGLT1&#46; There was a significant reduction in fasting blood glucose&#44; postprandial blood glucose and HbA<span class="elsevierStyleInf">1c </span>&#40;glycated haemoglobin&#41; in animal models&#44; while no changes were observed in plasma and urine electrolyte concentrations&#46;<span class="elsevierStyleSup">20</span></p><p class="elsevierStylePara">Of the SGLT2 inhibitors&#44; the most developed is dapagliflozin&#46;</p><p class="elsevierStylePara">Dapagliflozin is rapidly absorbed after oral administration in an average time of 1 hour &#40;0&#46;5hr-4&#46;0hr&#41; in patients with type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#46; A phase I study &#40;in healthy volunteers&#41; suggested that absorption was slower when given with meals&#44; although this difference was minimal&#46;<span class="elsevierStyleSup">21</span> The half-life of dapagliflozin is approximately 16 hours&#46; Glycosuria is dose-dependent&#46;</p><p class="elsevierStylePara">Dapagliflozin renal clearance is minimal &#40;3-6ml&#47;min&#41; and renal excretion is low &#40;less than 2&#46;5&#37; in urine over 24h&#41;&#46; <span class="elsevierStyleItalic">In vitro</span> studies have suggested that dapagliflozin is metabolised by metabolic inactivation of the enzyme glucuroniltransferase&#46;<span class="elsevierStyleSup">22</span></p><p class="elsevierStylePara">Dapagliflozin has showed a hypoglycaemic effect at daily doses of 2&#46;5mg&#44; 5mg&#44; 10mg&#44; 20mg and 50mg in phase II clinical trials&#46; Most of the ongoing phase III trials are evaluating the effects of daily doses of 2&#46;5mg&#44; 5mg and 10mg&#46;</p><p class="elsevierStylePara">The randomised&#44; double-blind&#44; placebo-controlled phase II study on dapagliflozin assessed dose-dependent effects in patients with type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#46; A total of 389 type 2 diabetic patients without treatment and with HbA<span class="elsevierStyleInf">1c</span> higher than 7&#37; were randomly assigned to a placebo group or a group treated with increasing doses of dapagliflozin for 12 weeks&#46;<span class="elsevierStyleSup">23</span> Metformin XR was the active comparator&#44; although no statistical comparisons were made&#46; Fasting blood glucose&#44; postprandial blood glucose using prolonged oral glucose overload &#40;3h&#41; and HbA<span class="elsevierStyleInf">1c</span> were assessed&#46;</p><p class="elsevierStylePara">Baseline HbA<span class="elsevierStyleInf">1c</span> ranged between 7&#46;7&#37; and 8&#46;0&#37; in all groups&#46; In the dapagliflozin group&#44; the decrease in HbA<span class="elsevierStyleInf">1c </span>was around 0&#46;8&#37;&#44; while in the placebo group it was 0&#46;2&#37; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#46; Dapagliflozin patients had glycosuria between 52-85g&#47;day&#44; with a reduction in fasting blood glucose between 16-30mg&#47;dl&#46; A weight loss of 2&#46;2kg-3&#46;2kg was observed in the group treated with dapagliflozin&#44; equivalent to an average weight loss of 2&#46;5&#37;-3&#46;4&#37;&#46; An increase in urine volume from 107 to 470ml&#47;day was also observed&#46;</p><p class="elsevierStylePara">Regarding adverse effects&#44; there was a slight increase in the incidence of urinary tract infections&#44; although this was not statistically significant&#46; There were no differences in the frequency of episodes of hypoglycaemia and hypotension between the groups&#46;</p><p class="elsevierStylePara">Dapagliflozin is currently in advanced development for use alone or in combination with other hypoglycaemic agents&#46; The drug was well tolerated in early stages&#44; with the following as the most common side effects&#58; urinary tract infections&#44; dizziness&#44; headache&#44; fatigue&#44; backache&#44; and nasopharyngitis&#46;<span class="elsevierStyleSup">24</span> Phase III studies include monotherapy in patients with type 2 <span class="elsevierStyleItalic">diabetes mellitus</span> not controlled with diet and exercise&#44; and in combination therapy with metformin&#44; sulphonylureas&#44; thiazolidinediones and insulin&#46;<span class="elsevierStyleSup">25-29</span></p><p class="elsevierStylePara">SGLT2 inhibitors are a novel group of drugs that appear to provide several advantages in the treatment of type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#58;</p><p class="elsevierStylePara">1&#46; Weight&#58; SGLT2 inhibitors promote weight loss by increasing glycosuria &#40;1g of glucose is equivalent to 4kcal&#41;&#44; which lowers plasma glucose levels and stimulates lipolysis&#46;</p><p class="elsevierStylePara">2&#46; It corrects a defective mechanism in type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#58; Increased tubular reabsorption of glucose has been shown in diabetic patients&#46;</p><p class="elsevierStylePara">3&#46; Adverse effects&#58; Hypoglycaemia is usually a barrier when considering strategies for optimal glycaemic control&#46; As inhibition of SGLT2 is completely independent of insulin secretion&#44; there is no increased risk of hypoglycaemia&#46;</p><p class="elsevierStylePara">4&#46; Treatment of hyperglycaemia&#58; The unique mechanism of SGLT2 inhibitors means they can probably be used alongside other hypoglycaemic treatments&#46;</p><p class="elsevierStylePara">The main concerns regarding inhibition of SGLT2 are the risk of urinary tract infections&#44; reduced intravascular volume secondary to osmotic diuresis&#44; electrolyte imbalance&#44; nephrotoxicity due to the accumulation of advanced glycation end products&#44; nocturia and drug interactions&#46; Long-term studies are required to address these concerns&#44; although the evidence obtained so far is sufficient to consider SGLT2 inhibitors as safe drugs&#46;</p><p class="elsevierStylePara">SGLT2 inhibitors may not be effective in patients with renal failure due to a reduced glomerular filtration rate&#44; although this is currently under investigation&#46; Studies are underway to identify the glomerular filtration rate cut-off point to contraindicate SGLT2 inhibitors&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara">Inhibition of the SGLT2 glucose transporter is a new therapeutic approach to type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#46; Studies in experimental models for diabetes have shown that induction of glycosuria reverts glucotoxicity&#44; restores normoglycaemia and improves beta cell function and insulin sensitivity&#46;</p><p class="elsevierStylePara">The fact that there are genetic mutations of the SGLT2 glucose transporter&#44; as occurs in renal glycosuria&#44; supports the long-term inhibition of this transporter in humans&#46; Preliminary results with dapagliflozin provide evidence of the efficacy of SGLT2 inhibitors in reducing fasting and postprandial blood glucose and decreasing HbA<span class="elsevierStyleInf">1c</span> in diabetic patients&#46;</p><p class="elsevierStylePara">Understanding the pathophysiology of type 2 diabetes is a dynamic process&#58; When new pathophysiological concepts arise&#44; new potential therapeutic tools are found&#46; The optimal treatment of type 2 <span class="elsevierStyleItalic">diabetes mellitus</span> requires a multiple approach to different defects in glucose homeostasis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara">1&#46; 55&#37; of glucose production comes from gluconeogenesis&#46; The kidney is responsible for 40&#37; of the glucose produced in gluconeogenesis&#44; which is equivalent to about 20&#37; of total glucose production&#46;</p><p class="elsevierStylePara">2&#46; In the kidney&#44; the main carrier for tubular reabsorption of glucose is SGLT2&#46;</p><p class="elsevierStylePara">3&#46; In renal glycosuria there is a mutation of the SCL5A2 gene&#44; which encodes SGLT2&#46; In these patients&#44; there is no increase in the incidence of diabetes or kidney disease&#46; The only finding in most cases is asymptomatic glycosuria&#46;</p><p class="elsevierStylePara">4&#46; An increase in SGLT2 transporter activity has been observed in diabetic patients&#44; resulting in increased tubular reabsorption of glucose&#46;</p><p class="elsevierStylePara">5&#46; SGLT2 inhibitors are emerging as a treatment for type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#44; due to inducing glycosuria and thus lowering plasma glucose and glucotoxicity&#46;</p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11410&#95;en&#95;w477710633910494&#95;18107&#95;6037&#95;es&#95;10494&#95;18102&#95;6037&#95;es&#95;tabla&#95;11&#95;copy1&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11410&#95;en&#95;w477710633910494&#95;18107&#95;6037&#95;es&#95;10494&#95;18102&#95;6037&#95;es&#95;tabla&#95;11&#95;copy1&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 1&#46; Comparison of SGLT1 and SGLT2 transporters </p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11411&#95;en&#95;w4777106331010494&#95;18107&#95;6038&#95;es&#95;10494&#95;18102&#95;6038&#95;es&#95;tabla&#95;2&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11411&#95;en&#95;w4777106331010494&#95;18107&#95;6038&#95;es&#95;10494&#95;18102&#95;6038&#95;es&#95;tabla&#95;2&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 2&#46; Sodium-glucose cotransporter family</p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11412&#95;en&#95;w4777106331110494&#95;18107&#95;6040&#95;es&#95;10494&#95;18102&#95;6040&#95;es&#95;tabla&#95;3&#95;copy1&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11412&#95;en&#95;w4777106331110494&#95;18107&#95;6040&#95;es&#95;10494&#95;18102&#95;6040&#95;es&#95;tabla&#95;3&#95;copy1&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 3&#46; SGLT2 transporter inhibitor drugs and development phase </p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11413&#95;en&#95;w4777106331310494&#95;figura&#95;1&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11413&#95;en&#95;w4777106331310494&#95;figura&#95;1&#95;en&#46;doc</a></p><p class="elsevierStylePara">Figure 1&#46; Mechanism of action of SGLT2</p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11414&#95;en&#95;w4777106331310494&#95;figuras&#95;2&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11414&#95;en&#95;w4777106331310494&#95;figuras&#95;2&#95;en&#46;doc</a></p><p class="elsevierStylePara">Figure 2&#46; Comparison of the maximum tubular glucose reabsorption capacity &#40;Tm&#41; </p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11415&#95;en&#95;w4777106331310494&#95;figura&#95;3&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11415&#95;en&#95;w4777106331310494&#95;figura&#95;3&#95;en&#46;doc</a></p><p class="elsevierStylePara">Figure 3&#46; Comparison of the glucose tubular transporters in diabetics and non-diabetics</p>"
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Type 2 sodium-glucose cotransporter (SGLT2) inhibitors: from familial renal glucosuria to the treatment of type 2 diabetes mellitus
Inhibidores del cotransportador sodio-glucosa tipo 2 (SGLT2): de la glucosuria renal familiar al tratamiento de la diabetes mellitus tipo 2
, G.. Pérez Lópezb, O.. González Albarránc, M.. Cano Megíasb
b Servicio de Endocrinología, Hospital Universitario Ramón y Cajal, Madrid,
c Servicio de Endocrinología, Hospital Universitario Ramón y Cajal, Madrid
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Glucose is filtered through the tubule and then transported via the tubular epithelial cells through the basolateral membrane into the peritubular capillary&#46; Under optimal conditions&#44; when tubular glucose load is approximately 120mg&#47;min or less&#44; there is no glucose loss in urine&#46; However&#44; when the glucose load exceeds approximately 220mg&#47;min &#40;glucose threshold&#41;&#44; glucose starts to appear in the urine&#46;</p><p class="elsevierStylePara">The blood glucose level required to provide such a tubular load covers a range of values in humans&#46; A study of this process reported that the blood glucose concentration required to exceed the tubular glucose threshold ranged between 130 and 300mg&#47;dl&#46;<span class="elsevierStyleSup">7</span> In addition&#44; the study found a relationship between age and increased threshold levels&#46;</p><p class="elsevierStylePara">90&#37; of filtered glucose is reabsorbed by the high absorption capacity of SGLT2 transporter in the convoluted segment of the proximal tubule&#44; and the remaining 10&#37; of filtered glucose is reabsorbed by the SGLT1 transporter in the straight segment of the descending proximal tubule&#46;<span class="elsevierStyleSup">2</span> As a result&#44; no glucose appears in the urine&#46;</p><p class="elsevierStylePara">The maximum renal capacity for tubular reabsorption &#40;Tm&#41; of glucose is greater in animal models with type 1 and type 2 diabetes&#46;<span class="elsevierStyleSup">8</span> In people with type 1 diabetes&#44; Mogensen et al&#46;<span class="elsevierStyleSup">9</span> showed that the glucose Tm is increased&#46; Conflicting results have been reported in patients with type 2 diabetes&#46;</p><p class="elsevierStylePara">Clinically&#44; the most common cause of glycosuria is diabetes&#46; Patients do not excrete glucose in the urine until the concentration of blood glucose is over 180mg&#47;dl&#44; which does not normally occur in people without diabetes&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Role of the SGLT2 transporter </span></p><p class="elsevierStylePara">The first step in the reabsorption of urine glucose involves the transport of glucose from the tubules to peritubular capillaries via tubular epithelial cells&#46;<span class="elsevierStyleSup">10</span> This is accomplished with the family of sodium-glucose cotransporters &#40;SGLT&#41;&#44; see Figure 1&#46; The SGLTs include a variety of membrane proteins that act on the transport of glucose&#44; amino acids&#44; vitamins&#44; ions and osmolytes across the brush border membrane of the renal proximal tubules and the intestinal epithelium&#46;<span class="elsevierStyleSup">11</span> SGLT1 is a low capacity and high affinity carrier&#46; It is found mainly in the gastrointestinal tract&#44; but can also be found in the S3 segment of the renal proximal tubule&#46; Although SGLT1 is the key transporter for glucose absorption in the gastrointestinal tract&#44; its impact on the kidney is less important&#59; representing about 10&#37; of glucose reabsorption&#46;</p><p class="elsevierStylePara">This has been of some pharmacological interest because blocking this transporter theoretically reduces the gastrointestinal absorption of glucose and may provide a method for inducing weight loss or reducing postprandial hyperglycaemia&#46;</p><p class="elsevierStylePara">By contrast&#44; SGLT2 transporter has a high capacity and low affinity&#44; and is found mainly in the kidney&#46; Table 1 compares the SGLT1 and SGLT2 transporters&#46;</p><p class="elsevierStylePara">A third member of this family&#44; SGLT3&#44; is widely found in skeletal muscle and the nervous system&#46; SGLT3 is not believed to be a glucose transporter&#44; but acts as a sensor&#46;<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">Although other members of this family have been identified &#40;SGLT4&#44; SGLT5 and SGLT6&#41;&#44; their role in humans is not known at this time &#40;Table 2&#41;&#46; The most prevalent and functionally most important transporter in the kidney is SGLT2&#46; It is responsible for 90&#37; of glucose reabsorption in the kidney&#44; and has become the subject of much interest in the diabetes field&#46;</p><p class="elsevierStylePara">This transporter is found in a relatively high proportion in the initial segment of the proximal tubule &#40;S1&#41;&#46; SGLT2 transports glucose by using the energy gradient of sodium reabsorption in the tubular filtration&#46; This process is called secondary active transport and is driven by the electrochemical gradient of sodium in the tubular filtration&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RENAL GLYCOSURIA&#58; SGLT2 TRANSPORTER INHIBITION MODEL</span></p><p class="elsevierStylePara">Renal glycosuria is a genetic condition where the effects of the inhibition of SGLT2 transporter can be observed&#46; Patients with this condition are asymptomatic&#44; even though in most cases they have a SLC5A2 gene mutation &#40;solute carrier family 5A&#41;&#44; responsible for encoding SGLT2 transporter protein&#46; Autosomal dominant and recessive inheritance patterns have been reported&#46; As a result of this mutation&#44; patients with renal glycosuria excrete in their urine more than 100g of glucose in 24 hours&#46;</p><p class="elsevierStylePara">Santer et al&#46;<span class="elsevierStyleSup">13</span> conducted a genetic study on 23 families diagnosed with renal glycosuria and found 21 different mutations of the SLC5A2 gene&#46; Fourteen out of the 21 families were homozygous and had glycosuria between 15 and 200g&#47;day&#46; Heterozygotes typically had glycosuria of under 4&#46;4g&#47;day&#44; although some did not&#46;</p><p class="elsevierStylePara">Two families diagnosed with renal glycosuria did not have the SLC5A gene mutation&#44; but may have had mutations of the genes encoding GLUT2 &#40;type 2 glucose transporter&#41;&#44; HNF-1&#945; &#40;hepatic nuclear factor 1 alpha&#41; which regulates the transcription of SGLT2 or genes related with SGLT1 or SGLT3&#46;</p><p class="elsevierStylePara">Except for glycosuria&#44; there were no other associated diseases&#46; Plasma glucose was high or low&#44; and blood volume remained essentially normal due to sodium reabsorption via other transporter channels&#46; Renal and bladder function was normal&#44; and this group of patients had no increased incidence of diabetes&#44; kidney disease or urinary tract infections&#44; compared with the general population&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">Figure 2 schematically shows the reabsorption of glucose in normal individuals and patients with renal glycosuria&#46; As mentioned previously&#44; the maximum renal capacity of tubular reabsorption &#40;Tm&#41; for glucose is variable&#44; although for physiological studies &#40;theoretical&#44; continuous black line&#41; it is about 198mg&#47;dl &#40;11mmol&#47;l&#41;&#46; The glucose Tm usually observed is below this figure &#40;broken black line&#41;&#44; and is saturated with glucose concentrations near 180mg&#47;dl &#40;10mmol&#47;l<span class="elsevierStyleSup">15</span>&#41;&#46;</p><p class="elsevierStylePara">Renal glycosuria can be classified into two types&#46;<span class="elsevierStyleSup">13</span> Type A has a glucose Tm lower than in normal subjects &#40;blue line&#41;&#46; These patients have decreased SGLT2 transporter activity as well as more significant glycosuria&#46;</p><p class="elsevierStylePara">In type B renal glycosuria&#44; the SGLT2 transporter has no affinity for glucose&#44; resulting in a decrease in the reabsorption rate of glucose&#44; but a normal glucose Tm &#40;green line&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">TYPE 2 <span class="elsevierStyleItalic">DIABETES MELLITUS</span> AND THE SGLT2 TRANSPORTER </span></p><p class="elsevierStylePara">Type 2 <span class="elsevierStyleItalic">diabetes mellitus</span> is associated with increased expression and activity of SGLT2&#46;</p><p class="elsevierStylePara">In a study<span class="elsevierStyleSup">16</span> of the SGLT2 transporter&#44; human exfoliated proximal tubular epithelial cells &#40;HEPTC&#41; were used&#44; which were obtained from urine samples&#46; HEPTC were isolated from healthy individuals and diabetic patients&#44; and were cultured in a hyperglycaemic medium&#46;</p><p class="elsevierStylePara">As shown in Figure 3&#44; the HEPTC of diabetic patients showed a statistically significant higher expression of SGLT2 and GLUT2 compared with non-diabetic individuals&#46; They also determined the renal glucose uptake using methyl-&#945;-D-&#91;U<span class="elsevierStyleSup">14</span>C&#93;-glucopyranoside &#40;AMG&#41;&#44; which is an analogue of glucose&#46; More glucose uptake was also observed in diabetes patients&#8217; HEPTC than in individuals without diabetes&#46;</p><p class="elsevierStylePara">These findings prove that the renal system noticeably contributes to the body&#39;s energy balance by regulating glucose uptake&#44; and that diabetic patients appear to be poorly adapted to this mechanism&#46; In diabetes&#44; glucose reabsorption may be increased in absolute terms by an increase of glucose Tm&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">SGLT2 TRANSPORTER INHIBITORS FOR THE TREATMENT OF TYPE 2 <span class="elsevierStyleItalic">DIABETES MELLITUS</span></span></p><p class="elsevierStylePara">In 1835&#44; French chemists isolated a substance called phlorizin from the roots of apple trees&#46; Although it was believed that phlorizin was a compound for treating fever&#44; infectious diseases and malaria&#44; it was not until 50 years after its discovery that it was found that high doses of phlorizin caused glycosuria&#46;<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">For several decades&#44; phlorizin was used in the assessment of renal physiology&#46; Then in 1970&#44; it was discovered that glycosuria could be caused by phlorizin inhibiting an active transport system for tubular reabsorption of glucose&#46; Between 1980 and 1990&#44; the SGLT2 transporter was identified&#44; and the inhibition of this transporter began to be profiled as a treatment for type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#46; Phlorizin was therefore the first known SGLT2 inhibitor&#46;</p><p class="elsevierStylePara">However&#44; phlorizin could not be used as a treatment for type 2 <span class="elsevierStyleItalic">diabetes mellitus</span> for several reasons&#46; Firstly&#44; because intestinal absorption is very poor and&#44; secondly&#44; because it does not just inhibit SGLT2&#44; it is also capable of inhibiting SGLT1&#44; causing osmotic diarrhoea in most cases&#46;</p><p class="elsevierStylePara">SGLT2 inhibition can reduce plasma glucose levels by reducing the glucose Tm&#44; resulting in increased urinary excretion of glucose&#46;</p><p class="elsevierStylePara">In animals without diabetes&#44; inhibition of SGLT2 has no effect on plasma glucose&#44; because hepatic glucose production is increased to compensate for glycosuria&#46; However&#44; in diabetic animals&#44; administration of SGLT2 inhibitors produces dose-dependent glycosuria and a significant reduction in plasma glucose&#46;</p><p class="elsevierStylePara">SGLT2 inhibition essentially resets the maladaptive diabetic kidney by reducing the affinity of the transporter and increasing glycosuria&#44; which decreases blood glucose and&#44; therefore&#44; glucotoxicity&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">Recently&#44; Phlorizin analogues selective for SGLT2 with better intestinal absorption have been developed&#46; Table 3 shows some drugs in this group&#44; including dapagliflozin and canagliflozin&#44; which are currently in phase III clinical trials&#46;</p><p class="elsevierStylePara">In addition&#44; one laboratory is currently in phase I clinical trials<span class="elsevierStyleSup">19 </span>with a molecule called ISIS-388626 to reduce expression of SGLT2&#46; This compound is an oligonucleotide that decreases transcription of the gene encoding the SGLT2 transporter&#46; In murine and canine models&#44; treatment with ISIS-388626 is highly selective&#44; as it reduces the mRNA &#40;messenger ribonucleic acid&#41; of SGLT2 by 80&#37; without modifying SGLT1&#46; There was a significant reduction in fasting blood glucose&#44; postprandial blood glucose and HbA<span class="elsevierStyleInf">1c </span>&#40;glycated haemoglobin&#41; in animal models&#44; while no changes were observed in plasma and urine electrolyte concentrations&#46;<span class="elsevierStyleSup">20</span></p><p class="elsevierStylePara">Of the SGLT2 inhibitors&#44; the most developed is dapagliflozin&#46;</p><p class="elsevierStylePara">Dapagliflozin is rapidly absorbed after oral administration in an average time of 1 hour &#40;0&#46;5hr-4&#46;0hr&#41; in patients with type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#46; A phase I study &#40;in healthy volunteers&#41; suggested that absorption was slower when given with meals&#44; although this difference was minimal&#46;<span class="elsevierStyleSup">21</span> The half-life of dapagliflozin is approximately 16 hours&#46; Glycosuria is dose-dependent&#46;</p><p class="elsevierStylePara">Dapagliflozin renal clearance is minimal &#40;3-6ml&#47;min&#41; and renal excretion is low &#40;less than 2&#46;5&#37; in urine over 24h&#41;&#46; <span class="elsevierStyleItalic">In vitro</span> studies have suggested that dapagliflozin is metabolised by metabolic inactivation of the enzyme glucuroniltransferase&#46;<span class="elsevierStyleSup">22</span></p><p class="elsevierStylePara">Dapagliflozin has showed a hypoglycaemic effect at daily doses of 2&#46;5mg&#44; 5mg&#44; 10mg&#44; 20mg and 50mg in phase II clinical trials&#46; Most of the ongoing phase III trials are evaluating the effects of daily doses of 2&#46;5mg&#44; 5mg and 10mg&#46;</p><p class="elsevierStylePara">The randomised&#44; double-blind&#44; placebo-controlled phase II study on dapagliflozin assessed dose-dependent effects in patients with type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#46; A total of 389 type 2 diabetic patients without treatment and with HbA<span class="elsevierStyleInf">1c</span> higher than 7&#37; were randomly assigned to a placebo group or a group treated with increasing doses of dapagliflozin for 12 weeks&#46;<span class="elsevierStyleSup">23</span> Metformin XR was the active comparator&#44; although no statistical comparisons were made&#46; Fasting blood glucose&#44; postprandial blood glucose using prolonged oral glucose overload &#40;3h&#41; and HbA<span class="elsevierStyleInf">1c</span> were assessed&#46;</p><p class="elsevierStylePara">Baseline HbA<span class="elsevierStyleInf">1c</span> ranged between 7&#46;7&#37; and 8&#46;0&#37; in all groups&#46; In the dapagliflozin group&#44; the decrease in HbA<span class="elsevierStyleInf">1c </span>was around 0&#46;8&#37;&#44; while in the placebo group it was 0&#46;2&#37; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#46; Dapagliflozin patients had glycosuria between 52-85g&#47;day&#44; with a reduction in fasting blood glucose between 16-30mg&#47;dl&#46; A weight loss of 2&#46;2kg-3&#46;2kg was observed in the group treated with dapagliflozin&#44; equivalent to an average weight loss of 2&#46;5&#37;-3&#46;4&#37;&#46; An increase in urine volume from 107 to 470ml&#47;day was also observed&#46;</p><p class="elsevierStylePara">Regarding adverse effects&#44; there was a slight increase in the incidence of urinary tract infections&#44; although this was not statistically significant&#46; There were no differences in the frequency of episodes of hypoglycaemia and hypotension between the groups&#46;</p><p class="elsevierStylePara">Dapagliflozin is currently in advanced development for use alone or in combination with other hypoglycaemic agents&#46; The drug was well tolerated in early stages&#44; with the following as the most common side effects&#58; urinary tract infections&#44; dizziness&#44; headache&#44; fatigue&#44; backache&#44; and nasopharyngitis&#46;<span class="elsevierStyleSup">24</span> Phase III studies include monotherapy in patients with type 2 <span class="elsevierStyleItalic">diabetes mellitus</span> not controlled with diet and exercise&#44; and in combination therapy with metformin&#44; sulphonylureas&#44; thiazolidinediones and insulin&#46;<span class="elsevierStyleSup">25-29</span></p><p class="elsevierStylePara">SGLT2 inhibitors are a novel group of drugs that appear to provide several advantages in the treatment of type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#58;</p><p class="elsevierStylePara">1&#46; Weight&#58; SGLT2 inhibitors promote weight loss by increasing glycosuria &#40;1g of glucose is equivalent to 4kcal&#41;&#44; which lowers plasma glucose levels and stimulates lipolysis&#46;</p><p class="elsevierStylePara">2&#46; It corrects a defective mechanism in type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#58; Increased tubular reabsorption of glucose has been shown in diabetic patients&#46;</p><p class="elsevierStylePara">3&#46; Adverse effects&#58; Hypoglycaemia is usually a barrier when considering strategies for optimal glycaemic control&#46; As inhibition of SGLT2 is completely independent of insulin secretion&#44; there is no increased risk of hypoglycaemia&#46;</p><p class="elsevierStylePara">4&#46; Treatment of hyperglycaemia&#58; The unique mechanism of SGLT2 inhibitors means they can probably be used alongside other hypoglycaemic treatments&#46;</p><p class="elsevierStylePara">The main concerns regarding inhibition of SGLT2 are the risk of urinary tract infections&#44; reduced intravascular volume secondary to osmotic diuresis&#44; electrolyte imbalance&#44; nephrotoxicity due to the accumulation of advanced glycation end products&#44; nocturia and drug interactions&#46; Long-term studies are required to address these concerns&#44; although the evidence obtained so far is sufficient to consider SGLT2 inhibitors as safe drugs&#46;</p><p class="elsevierStylePara">SGLT2 inhibitors may not be effective in patients with renal failure due to a reduced glomerular filtration rate&#44; although this is currently under investigation&#46; Studies are underway to identify the glomerular filtration rate cut-off point to contraindicate SGLT2 inhibitors&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara">Inhibition of the SGLT2 glucose transporter is a new therapeutic approach to type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#46; Studies in experimental models for diabetes have shown that induction of glycosuria reverts glucotoxicity&#44; restores normoglycaemia and improves beta cell function and insulin sensitivity&#46;</p><p class="elsevierStylePara">The fact that there are genetic mutations of the SGLT2 glucose transporter&#44; as occurs in renal glycosuria&#44; supports the long-term inhibition of this transporter in humans&#46; Preliminary results with dapagliflozin provide evidence of the efficacy of SGLT2 inhibitors in reducing fasting and postprandial blood glucose and decreasing HbA<span class="elsevierStyleInf">1c</span> in diabetic patients&#46;</p><p class="elsevierStylePara">Understanding the pathophysiology of type 2 diabetes is a dynamic process&#58; When new pathophysiological concepts arise&#44; new potential therapeutic tools are found&#46; The optimal treatment of type 2 <span class="elsevierStyleItalic">diabetes mellitus</span> requires a multiple approach to different defects in glucose homeostasis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara">1&#46; 55&#37; of glucose production comes from gluconeogenesis&#46; The kidney is responsible for 40&#37; of the glucose produced in gluconeogenesis&#44; which is equivalent to about 20&#37; of total glucose production&#46;</p><p class="elsevierStylePara">2&#46; In the kidney&#44; the main carrier for tubular reabsorption of glucose is SGLT2&#46;</p><p class="elsevierStylePara">3&#46; In renal glycosuria there is a mutation of the SCL5A2 gene&#44; which encodes SGLT2&#46; In these patients&#44; there is no increase in the incidence of diabetes or kidney disease&#46; The only finding in most cases is asymptomatic glycosuria&#46;</p><p class="elsevierStylePara">4&#46; An increase in SGLT2 transporter activity has been observed in diabetic patients&#44; resulting in increased tubular reabsorption of glucose&#46;</p><p class="elsevierStylePara">5&#46; SGLT2 inhibitors are emerging as a treatment for type 2 <span class="elsevierStyleItalic">diabetes mellitus</span>&#44; due to inducing glycosuria and thus lowering plasma glucose and glucotoxicity&#46;</p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11410&#95;en&#95;w477710633910494&#95;18107&#95;6037&#95;es&#95;10494&#95;18102&#95;6037&#95;es&#95;tabla&#95;11&#95;copy1&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11410&#95;en&#95;w477710633910494&#95;18107&#95;6037&#95;es&#95;10494&#95;18102&#95;6037&#95;es&#95;tabla&#95;11&#95;copy1&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 1&#46; Comparison of SGLT1 and SGLT2 transporters </p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11411&#95;en&#95;w4777106331010494&#95;18107&#95;6038&#95;es&#95;10494&#95;18102&#95;6038&#95;es&#95;tabla&#95;2&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11411&#95;en&#95;w4777106331010494&#95;18107&#95;6038&#95;es&#95;10494&#95;18102&#95;6038&#95;es&#95;tabla&#95;2&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 2&#46; Sodium-glucose cotransporter family</p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11412&#95;en&#95;w4777106331110494&#95;18107&#95;6040&#95;es&#95;10494&#95;18102&#95;6040&#95;es&#95;tabla&#95;3&#95;copy1&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11412&#95;en&#95;w4777106331110494&#95;18107&#95;6040&#95;es&#95;10494&#95;18102&#95;6040&#95;es&#95;tabla&#95;3&#95;copy1&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 3&#46; SGLT2 transporter inhibitor drugs and development phase </p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11413&#95;en&#95;w4777106331310494&#95;figura&#95;1&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11413&#95;en&#95;w4777106331310494&#95;figura&#95;1&#95;en&#46;doc</a></p><p class="elsevierStylePara">Figure 1&#46; Mechanism of action of SGLT2</p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11414&#95;en&#95;w4777106331310494&#95;figuras&#95;2&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11414&#95;en&#95;w4777106331310494&#95;figuras&#95;2&#95;en&#46;doc</a></p><p class="elsevierStylePara">Figure 2&#46; Comparison of the maximum tubular glucose reabsorption capacity &#40;Tm&#41; </p><p class="elsevierStylePara"><a href="10494&#95;108&#95;11415&#95;en&#95;w4777106331310494&#95;figura&#95;3&#95;en&#46;doc" class="elsevierStyleCrossRefs">10494&#95;108&#95;11415&#95;en&#95;w4777106331310494&#95;figura&#95;3&#95;en&#46;doc</a></p><p class="elsevierStylePara">Figure 3&#46; Comparison of the glucose tubular transporters in diabetics and non-diabetics</p>"
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        "resumen" => "<p class="elsevierStylePara">For centuries&#44; the kidney has been considered primarily an organ of elimination and a regulator of salt and ion balance&#46; Although once thought that the kidney was the structural cause of diabetes&#44; which in recent years has been ignored as a regulator of glucose homeostasis&#44; is now recognized as a major player in the field of metabolic regulation carbohydrate&#46; During fasting&#44; 55&#37; of the glucose comes from gluconeogenesis&#46; Only 2 organs have this capability&#58; the liver and kidney&#46; The latter is responsible for 20&#37; of total glucose production and 40&#37; of that produced by gluconeogenesis&#46; Today we have a better understanding of the physiology of renal glucose transport via specific transporters&#44; such as type 2 sodium-glucose cotransporter&#160; &#40;SGLT2&#41;&#46; A natural compound&#44; phlorizin&#44; was isolated in early 1800 and for decades played an important role in diabetes and renal physiology research&#46; Finally&#44; at the nexus of these findings mentioned above&#44; recognized the effect of phlorizin-like compounds in the renal glucose transporter&#44; which has offered a new mechanism to treat hyperglycemia&#46; This has led to the development of several potentially effective treatment modalities for the treatment of diabetes&#46;</p>"
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