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Abstract Background and Aims The sodium-glucose co-transporter type 2 inhibitors (SGLT2i) such as dapagliflozin and empagliflozin, are a new class of nephro- and cardio-protective drugs in diabetic and non-diabetic patients. SGLT2 is greatly expressed in the proximal tubule cells, and therefore the protective effects of gliflozins are thought to be mediated by a hemodynamic mechanism on glomerular hyperfiltration. However, they could be acting also in other cell types, particularly in diabetic patients, because hyperglycemia induces the expression of SGLT2 in endothelial cells, mesangial cells, cardiomyocytes, etc. Because SGLT2 changes the intracellular concentration of sodium and glucose, gliflozins may indirectly change mitochondrial swelling and activity. In this study, we have tested the hypothesis that gliflozins act on mitochondria in patients suffering from diabetes. Method We have analyzed kidney biopsies from diabetic patients in treatment with a gliflozin (n = 10) or without gliflozin treatment (n = 10) stained with fuchsin red, which gives a color intensity proportional to mitochondrial content. Clinical variables (albumin-creatinine ratio (ACR), blood pressure, eGFR, glycated albumin) have been measured before and after 4 months of treatment. Images have been acquired using a Zeiss Axioscope with 100x objective and analyzed using ImageJ software to quantify staining intensity (expressed as optical density) after background subtraction. Two different cell types have been considered: proximal tubule cells and endothelial cells in glomeruli. Only non-sclerotic glomeruli have been considered. Results The systolic blood pressure was linearly correlated to the intensity of staining of mitochondria in the proximal tubule cells in all patients irrespective of gliflozin treatment. In non-treated diabetic patients, the mitochondrial content of endothelial cells was not related to the extent of ACR reduction over time. In diabetic patients treated with gliflozins, the extent of ACR reduction after treatment was correlated with the intensity of mitochondrial staining in glomerular endothelial cells. This correlation was not present in proximal tubule cells. Gliflozin treatment may induce a change in the mitochondrial content of endothelial cells, particularly in patients responding with a reduction in proteinuria. Conclusion Proteinuria in diabetic patients depends on damage in both the endothelial and podocyte compartments. Gliflozins may improve proteinuria by a hemodynamic mechanism; however, our data suggest an effect of gliflozins specific on mitochondria of the endothelial cells in the glomeruli, which is proportional to their anti-proteinuric effect. Though we do not analyze the mechanism of gliflozins on mitochondria, it is possible to speculate that the changes of intracellular sodium-induced by gliflozins may induce an altered mitochondrial activity.
Borriello et al. (Wed,) studied this question.