Effects of Empagliflozin in chronic kidney disease on hemodialysis patients

Effects of Empagliflozin in chronic kidney disease on hemodialysis patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Empagliflozin in chronic kidney disease on hemodialysis patients Mohamad tarek kattan, Sami albitar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7643324/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Several risk factors in chronic kidney disease (CKD) patients cause mortality; cardiovascular risk is the most important one. So, new protective treatments have to be added to the management of CKD patients; the most important one are renin angiotensin aldosterone system inhibitors (RAASI), but the latest one are sodium glucose transporter 2 inhibitors (SGLT2i). Here in this study, we tried to approve cardiac and hematologic benefits of Empagliflozine using in end stage renal disease (ESRD) on renal replacement therapy (RRT) patients. Methods: we started Empagliflozin 10 mg for 9 months in 17 hemodialysis patients. Echocardiography and serum hemoglobin to measure cardiac parameters (interventricular septum diameter {IVSD} and ejection fraction{EF%}) and serum hemoglobin (HG) levels were done at baseline and after 9 months. We included diabetic and non-diabetic patients in our study. Patients with urinary anomalies were excluded. Statistical analysis was done to the results by IBM SPSS program to evaluate the benefits. Results: We included 17 participants, 64.7 % of them were male and 35.3% were female. There ages ranges from 22 years old to 75. Results declared cardiac benefits, as interventricular septum diameter(IVSD) was reduced by mean of 0.08 cm (p.value 0.002), (Std.Deviation(0.088), and increased left ventricular ejection fraction (EF%) by mean of 2.7 % after treatment. (p.value 0.15), (Std.Deviation (7.48), and hematologic benefits, as hemoglobin increased by mean of 0.68 mg/dl (p.value 0.001), (Std.Deviation (0.67), with no important side effects. Conclusion: We concluded that, using empagliflozin in hemodialysis patients, improved cardiac function and increased hemoglobin levels with statistically significance, and may improve prognosis and quality of life. Chronic kidney disease Ejection fraction Hemoglobin Interventricular septum diameter Sodium glucose transporter 2 inhibitors Figures Figure 1 Figure 2 Figure 3 Key learning points -Currently, the safety and efficacy of initiating SGLT2i for people with an eGFR <20 ml/min per 1.73 m2, are not established. -This study considered the first one, that expertise SGLT2I effects on cardiac and hematologic parameters in end stage renal disease (ESRD) patients, who are treated with hemodialysis, and suggested that, giving empagliflozin in CKD patients on hemodialysis, has positive results on hemoglobin levels, and cardiac structure parameters. -This study concluded that, using SGLT2I has also benefits in ESRD patients, that overwhelm the limitations of their use, and may improve the quality of life and prognosis. Introduction Chronic kidney disease (CKD) is a worldwide threat to public health and has a risk-multiplier effect on major noncommunicable diseases, including cardiovascular diseases. More than 322 million individuals are currently affected by CKD worldwide, and the number of patients with end-stage renal disease (ESRD) treated with renal replacement therapy (RRT) with dialysis or transplantation globally exceeds 2.6 million people.3 Independent of the initial insult, progression to ESRD is relatively common in chronic nephropathies. Although genetic factors contribute to susceptibility and progression of renal disease, increased glomerular capillary flow and pressure consistently leading to increased urinary protein traffic have been claimed as independent factors of progression and poor renal outcomes in nondiabetic and diabetic kidney disease. Sodium glucose cotransporter protein subtype-2 (SGLT-2) in the renal proximal convoluted tubule is blocked by SGLT-2 inhibitors, thereby increasing renal excretion of glucose. There are increased risks for genital mycotic infections and, rarely, urinary tract infections; thus patients taking these should be cautioned. Although many patients with chronic kidney disease (CKD) progress to end-stage renal disease (ESRD) and require renal replacement therapy (RRT), the majority die of nonrenal causes, particularly premature cardiovascular (CV) events. Early diagnosis of CKD is therefore important because it provides opportunities to delay progression of CKD and prevent CV complications. Management of CKD should be aimed at slowing the rate of decline of kidney function and minimizing the effects of other complications. SGLT2 inhibitors induce osmotic diuresis and have natriuretic effects contributing to plasma volume contraction. They decrease systolic and diastolic BP by 4 to 6/1 to 2 mm Hg, respectively. They also decrease weight. SGLT2 inhibition is associated with an acute, dose-dependent reduction in eGFR by approximately 5 ml/min/1.73 m2 and approximately 30% to 40% reduction in albuminuria. These effects mirror preclinical observations suggesting that proximal tubular natriuresis activates renal tubuloglomerular feedback through increased macula densa sodium and chloride delivery, leading to afferent vasomodulation. Glycosuric effects are attenuated in patients with CKD (eGFR < 60 ml/min/1.73 m2 ) but BP, eGFR, and albuminuria lowering effects are preserved. some guidelines now recommend that SGLT2 inhibitors with proven CV benefit be prioritized.. in patients with type 2 diabetes with insufficient glycemic control and who have atherosclerotic CVD. Furthermore, the EMPA-REG OUTCOME study reported a 39% reduction in incident or worsening nephropathy that included doubling of serum creatinine (relative risk reduction, 44%) and renal-replacement therapy (relative risk reduction, 55%) in the empagliflozin group, while the CANVAS-Renal trial similarly reported an impressive 40% reduction in the composite renal outcome (defined as a sustained 40% reduction in the rate of eGFR decline, need for renal replacement therapy, or death from renal causes). In this study we tried to approve benefits of SGLT2I using in ESRD on hemodialysis patients on cardiovascular and hematologic effect and subsequently on prognosis. Material and methods We started daily Empagliflozin 10 mg in 17 hemodialysis patients, who are on intermittent hemodialysis with twice weekly sessions, in the hemodialysis unit at Aleppo university hospital, to evaluate cardiac and hematologic benefits after 9 months of treatment. We randomized the patients regardless of the cause of ESRD (Diabetes, FSGS, Analgesic nephropathy,), the age, the sex, the residual kidney function, and dialysis duration. We excluded patients who have urinary anomalies. At baseline and after 9 months, we did echocardiography to measure cardiac parameters (left ventricular ejection fraction {EF%} and Interventricular septum diameter{IVSD}), and hemoglobin levels to all participants in our study. Patients were prospectively monitored through 9 months to check benefits and possible side effects of the treatment. We analyzed the results, and did statistical study and analyzing charts by IBM SPSS program version 18. A P. value < 0.05 was considered as statistically significant. Results We randomized 17 patients on hemodialysis treatment (two sessions weekly), 64.7 % of them were male and 35.3% were female. There ages ranges from 22 years old to 75. Table 1 patient’s characters and treatment outcomes Month 0 Month 9 Month 0 Month 9 AGE SEX Hemoglobin Hemoglobin IVSD EF% IVSD EF% 1 70 male 8 9 1.8 42 1.57 65 2 39 female 9 10 1.25 60 1.3 60 3 38 male 9.3 10 1.34 55 1.25 55 4 22 female 7.4 7.9 2.35 62 2.25 60 5 55 male 7.4 9.7 1.49 33 1.3 40 6 50 female 7.3 8.5 1.19 60 1.11 60 7 55 male 9 9.3 1.35 55 1.3 55 8 50 male 7.5 7.8 1.94 67 1.8 65 9 55 male 11.7 12 1.7 65 1.5 67 10 75 male 13.6 13.2 1.5 25 1.47 35 11 50 male 12 12.3 1.22 61 1.24 64 12 50 male 10 9.5 1.1 35 1.1 35 13 45 male 10 11 0.97 55 0.9 60 14 60 female 9.5 10 1.3 50 1.34 53 15 24 female 7.5 9 1.1 73 1.1 73 16 65 male 7.4 8.5 1.2 55 1.2 55 17 35 male 11 11.5 1.3 60 1.2 60 The causes of chronic kidney disease in participants were: diabetes (23.5%), GN (29.4%), HTN (29.4%), and analgesic nephropathy (23.5%). Table 2 shows the mean and standard deviation of variables values before and after treatment MEAN NUMBER Standard deviation Hemoglobin before treatment 9.27 17 1.91 Hemoglobin after treatment 9.95 17 1.56 Ejection fraction before treatment 53.7 17 12.93 Ejection fraction after treatment 56.41 17 8.9 IVSD before treatment 1.42 17 0.34 IVSD after treatment 1.34 17 0.31 Table 3 shows the mean, standard deviation, and the p.value of paired differences of variables before and after treatment Paired Differences Sig. (2-tailed) p.value Mean Std. Deviation Std. Error Mean 95% Confidence Interval of the Difference Lower Upper Pair 1 Hemoglobin before treatment -Hemoglobin after treatment - 0 .6824 0.6748 0.1637 -1.0293- - 0 .3354- 0.001 Pair 2 Ejection fraction before treatment - Ejection fraction after treatment -2.70588 7.48970 1.81652 -6.55673- 1.14497 0.156 Pair 3 IVSD before treatment - IVSD after treatment 0.08059 0.08856 0.02148 0.03505 0.12612 0.002 After treatment with Empagliflozin 10 mg daily for 9 months, we noticed a significant improvement in the hemoglobin levels, as it increased by mean of 0.68 mg/dl (p.value 0.001), (Std.Deviation (0.67), with statistically significance, as the mean value before treatment was (9.27) mg/dl with standard deviation (1.91), While The mean value after treatment increased to (9.95) mg/dl with standard deviation (1.56). Fig1 In addition, The Ejection fraction of left ventricle increased by mean of 2.7 % after treatment. (p.value 0.15), (Std.Deviation (7.48)), with no statistically significance, as the mean value before treatment was (53.7%) with Std. Deviation (12.93), while it was after treatment (56.4%) with Std. Deviation (8.90). Fig2 Also, the study approved an important reduction in the mean value of IVSD (interventricular septum diameter), as it reduced by mean of 0.08 cm (p.value 0.002), (Std.Deviation(0.088)), with statistically significance, as The mean value before treatment was (1.42cm), with Std. Deviation (0.34), while it was (1.34cm) with Std. Deviation (0.31) after treatment. Fig3 Discussion Sodium glucose cotransporter protein subtype-2 (SGLT-2) in the renal proximal convoluted tubule is blocked by SGLT-2 inhibitors, thereby increasing renal excretion of glucose. There are increased risks for genital mycotic infections and, rarely, urinary tract infections; thus patients taking these should be cautioned. In the EMPA-REG OUTCOME trial, patients with T2DM and GFR greater than 90 to 45 ml/min/1.73 m2 were recruited. Empagliflozin was seen to reduce the risk for CV mortality, all-cause mortality, and hospitalization for congestive heart failure with favorable effects on weight, systolic blood pressure (BP), and serum uric acid. This is consistent with previous reports of SGLT-2 inhibitors on reducing CV and all-cause mortality. EMPA-REG OUTCOME also reported a reduction in doubling of serum creatinine and renal replacement therapy (RRT) while reducing progression to macroalbuminuria; however, the perceived renal benefits cannot be fully explained by the moderate reduction in HbA1c, BP, or serum uric acid. It has been postulated that SGLT-2 inhibitors decrease proximal tubular reabsorption of sodium that increases distal sodium delivery to the macula densa that in turns activates tubuloglomerular feedback, resulting in afferent vasodilatation and a reduction of hyperfiltration. There is a reduction in intraglomerular pressure, BP, blood glucose, and blood volume. In addition, the increase in ketone body metabolism is thought to induce an energy-efficient oxygen consumption state at the mitochondrial level that reduces hypoxic stress in the kidney, reducing renal progression of DN. ü In our study, we found similar results as worldwide studies approved, about improving cardiac structure (improved diastolic function and reduced interventricular septum diameter, but there were no significant effect on left ventricular ejection fraction, in addition giving empagliflozin in CKD patients on RRT had also positive results on hemoglobin levels (increased hemoglobin by 0.68g/dl after 9 months), But The important difference in our study is that, our cohort was ESRD patients on renal replacement therapy. these results mean that, improvement in cardiac structure, function, and hemoglobin levels, was achieved until in more advanced CKD patients with lower eGFR value, so we recommend to do larger trials to advance evidence and approve the benefits Main limitations were, The small number of patients, and Patients no adherence to treatment. We advise to use Sglt2i in ESRD patients in special cases (such as heart failure with reduced ejection fraction, left ventricular hypertrophy LVH, and as additional therapy for anemia). Conclusion Our study is the first one, that studied the effects of Empagliflozin on cardiac structure, and hemoglobin levels on hemodialysis patients. Here, we approved that, using Empagliflozin had cardiac and hematologic benefits, as the majority of patients had higher hemoglobin levels, and less interventricular septum diameter(IVSD) on echocardiography after treatment with Empagliflozin, with no important side effects that limit the using of these drugs. These are promised results to be added to the medical literature. Declarations Acknowledgements: Not applicable. Competing interests and funding: The authors declare that there are no competing interest regarding the publication of this paper, and No funding was involved in this study. Ethics approval and accordance: The protocol was approved by (Aleppo university hospital/university of Aleppo) in accordance with the guidelines and regulations : -minimizing harm to participants -obtaining informed consent from research subjects -protecting participant’s anonymity and confidentiality. -avoiding deceptive practices in research. -respecting the rights and dignity of research subjects Consent to participate: Informed consent was taken from all participants. Consent to publish: Not applicable in this manuscript Data Availability: All datasets generated or analyzed during this study are included in this published article. Author’s contributions: Dr.Sami albitar did the general review, patients treatment and monitoring. Dr.Mohamad Kattan participated in patients treatment and did the information collection and writing. Note: The words beside the marker ü is the author’s words. References John Feehally, DM, FRCP ,Jürgen Floege, MD, FERA ,Marcello Tonelli, MD, SM, MSc, FRCPC ,Richard J. Johnson, MD , Comprehensive Clinical Nephrology SIXTH EDITION © 2019, Elsevier Inc, ISBN: 978-0-323-47909-7 E-ISBN: 978-0-323-54719-2, 2015v1.0, 913,935,938,378,389,390 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7643324","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":545824156,"identity":"cc53ffba-d0e6-46d9-96d5-86645d9ea3ab","order_by":0,"name":"Mohamad tarek kattan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABGklEQVRIie2PMUvDQBTHIwfX5SDrC5H0EwhXDoKQL2MJpMvd7hBKp7jEzopfolk6Gw7jcnY+0KEQcHASA12U4iWIU1rtJnK/4c/j8X7wf45jsfxJSBuoi6NZt0G3JuD4JwW+FGoGfNYq5BCF0O99HycXl+WbPo+m7o2Uo6v0wwx586LTU+IM5N2iRwnVKva5mgCskni8qCjA08My4pUpRpJE9ymaU19kEhxFWLnGppgWS8axUYCEOxT2LrYShsptyvWWwlDzZ8a3e5XQFzMJVBE0LjIKVHNUi2yPolRomk+8QmE2up4zr9BJiMQcCN71y33OHnkauYFCtZdvAjfQcd3wzTRwB7LqU3rB0OVvz1vQ6yHXFovF8u/5BMl8Y6oHLZdPAAAAAElFTkSuQmCC","orcid":"","institution":"University of Aleppo","correspondingAuthor":true,"prefix":"","firstName":"Mohamad","middleName":"tarek","lastName":"kattan","suffix":""},{"id":545824161,"identity":"08c165e5-8975-44ce-aee2-820f6eaf47e5","order_by":1,"name":"Sami albitar","email":"","orcid":"","institution":"University of Aleppo","correspondingAuthor":false,"prefix":"","firstName":"Sami","middleName":"","lastName":"albitar","suffix":""}],"badges":[],"createdAt":"2025-09-17 20:08:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7643324/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7643324/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96071556,"identity":"1b6a19ab-978e-4e66-816f-37cc969afe22","added_by":"auto","created_at":"2025-11-17 10:00:55","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":87072,"visible":true,"origin":"","legend":"","description":"","filename":"originalarticle1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/84a57ac8de2da481f7b3c759.docx"},{"id":96071553,"identity":"e9e85891-0483-4ed2-a1cf-1d405c855771","added_by":"auto","created_at":"2025-11-17 10:00:55","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4579,"visible":true,"origin":"","legend":"","description":"","filename":"cced2f41ae9b442885b31dd6b88a4e13.json","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/7fcc1a7f919979f90f2e7ba7.json"},{"id":96071554,"identity":"96078941-0619-4b12-ba89-0d992d7aa338","added_by":"auto","created_at":"2025-11-17 10:00:55","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":47388,"visible":true,"origin":"","legend":"","description":"","filename":"cced2f41ae9b442885b31dd6b88a4e131enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/2c1bca94053235661e5120af.xml"},{"id":96071552,"identity":"2f484b30-d8dc-42d8-a1cf-81110f064a85","added_by":"auto","created_at":"2025-11-17 10:00:55","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":12403,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/63fa8729e488c1064bfb21aa.png"},{"id":96248229,"identity":"f12c2548-fd15-415a-ac55-19c0143a5e8b","added_by":"auto","created_at":"2025-11-19 07:28:11","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10523,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/770b936fbdb12f1ed5212a49.png"},{"id":96248608,"identity":"1c71b095-42be-4d1d-901b-962cd2f9775f","added_by":"auto","created_at":"2025-11-19 07:28:47","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10659,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/345a6f11dde8cf17355b48a9.png"},{"id":96071560,"identity":"272a26d4-004d-49f7-8817-511e17a43689","added_by":"auto","created_at":"2025-11-17 10:00:56","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6904,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/7cf56d9bdf9433326189b1e8.png"},{"id":96071557,"identity":"2f7d0083-5b13-4b51-96f0-24254e968463","added_by":"auto","created_at":"2025-11-17 10:00:55","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6927,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/7d2fd15c0ae3dfb38deb7182.png"},{"id":96071562,"identity":"a1eabb28-953f-4235-a34c-623c5611654f","added_by":"auto","created_at":"2025-11-17 10:00:56","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6730,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/0a9995803f9f99801dcad63b.png"},{"id":96247259,"identity":"9f97da05-89cf-4a11-8125-048b79cafe2c","added_by":"auto","created_at":"2025-11-19 07:27:19","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":42865,"visible":true,"origin":"","legend":"","description":"","filename":"cced2f41ae9b442885b31dd6b88a4e131structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/15f85d89933d8a5a401729c7.xml"},{"id":96071564,"identity":"ff3526f4-dfd5-4eb8-96a2-c7366bf9ee68","added_by":"auto","created_at":"2025-11-17 10:00:56","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51650,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/51e99e3a6a984ddf65c7fc2e.html"},{"id":96071550,"identity":"fec73f9e-db6a-4081-a83c-0db0c87d7fa7","added_by":"auto","created_at":"2025-11-17 10:00:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":135623,"visible":true,"origin":"","legend":"\u003cp\u003eshows a comparision between mean hemoglobin values before and after treatment\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/2615662e9002c512c8c9a8ef.png"},{"id":96071551,"identity":"6c68df09-b8e8-4301-87e2-abfb7ac7018a","added_by":"auto","created_at":"2025-11-17 10:00:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":270358,"visible":true,"origin":"","legend":"\u003cp\u003eshows a comparison between mean values of EF% before and after treatment\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/bfc3518ee04d3bf8bfc73cca.png"},{"id":96071558,"identity":"8c6ca73a-e180-4b3a-bb86-bb4b24d260b7","added_by":"auto","created_at":"2025-11-17 10:00:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":248856,"visible":true,"origin":"","legend":"\u003cp\u003eshows mean of IVSD values before and after treatment\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/a1855049febc3979689d1f70.png"},{"id":98441286,"identity":"24fb4918-691c-4d17-8c72-634c9d506e10","added_by":"auto","created_at":"2025-12-17 17:05:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":975454,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7643324/v1/08aa8ec7-0124-4b11-826e-9a50f1a769db.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of Empagliflozin in chronic kidney disease on hemodialysis patients","fulltext":[{"header":"Key learning points","content":"\u003cp\u003e-Currently, the safety and efficacy of initiating SGLT2i for people with an eGFR \u0026lt;20 ml/min per 1.73 m2, are not\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eestablished.\u003c/p\u003e\n\u003cp\u003e-This study considered the first one, that expertise SGLT2I effects on cardiac and hematologic parameters in end stage renal disease (ESRD) patients, who are treated with hemodialysis, and suggested that, giving empagliflozin in CKD patients on hemodialysis, has positive results on hemoglobin levels, and cardiac structure parameters.\u003c/p\u003e\n\u003cp\u003e-This study concluded that, using SGLT2I has also benefits in ESRD patients, that overwhelm the limitations of their use, and may improve the quality of life and prognosis.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eChronic kidney disease (CKD) is a worldwide threat to public health and has a risk-multiplier effect on major noncommunicable diseases, including cardiovascular diseases. More than 322\u0026nbsp;million individuals\u003c/p\u003e\u003cp\u003eare currently affected by CKD worldwide, and the number of patients with end-stage renal disease (ESRD) treated with renal replacement therapy (RRT) with dialysis or transplantation globally exceeds 2.6\u003c/p\u003e\u003cp\u003e million people.3 Independent of the initial insult, progression to ESRD is relatively common in chronic nephropathies. Although genetic factors contribute to susceptibility and progression of renal disease, increased glomerular capillary flow and pressure consistently leading to increased urinary protein traffic have been claimed as independent factors of progression and poor renal outcomes in nondiabetic and diabetic kidney disease.\u003c/p\u003e\u003cp\u003eSodium glucose cotransporter protein subtype-2 (SGLT-2) in the renal proximal convoluted tubule is blocked by SGLT-2 inhibitors, thereby increasing renal excretion of glucose. There are increased risks for genital\u003c/p\u003e\u003cp\u003emycotic infections and, rarely, urinary tract infections; thus patients taking these should be cautioned.\u003c/p\u003e\u003cp\u003eAlthough many patients with chronic kidney disease (CKD) progress to end-stage renal disease (ESRD) and require renal replacement therapy (RRT), the majority die of nonrenal causes, particularly premature cardiovascular (CV) events. Early diagnosis of CKD is therefore important because it provides opportunities to delay progression of CKD and prevent CV complications.\u003c/p\u003e\u003cp\u003eManagement of CKD should be aimed at slowing the rate of decline of kidney function and minimizing the effects of other complications.\u003c/p\u003e\u003cp\u003eSGLT2 inhibitors induce osmotic diuresis and have natriuretic effects contributing to plasma volume contraction. They decrease systolic and diastolic BP by 4 to 6/1 to 2 mm Hg, respectively. They also decrease\u003c/p\u003e\u003cp\u003eweight. SGLT2 inhibition is associated with an acute, dose-dependent reduction in eGFR by approximately 5 ml/min/1.73 m2 and approximately 30% to 40% reduction in albuminuria. These effects mirror\u003c/p\u003e\u003cp\u003epreclinical observations suggesting that proximal tubular natriuresis activates renal tubuloglomerular feedback through increased macula densa sodium and chloride delivery, leading to afferent vasomodulation. Glycosuric effects are attenuated in patients with CKD (eGFR\u0026thinsp;\u0026lt;\u0026thinsp;60 ml/min/1.73 m2 ) but BP, eGFR, and albuminuria lowering effects are preserved. some guidelines now recommend that SGLT2 inhibitors with proven CV benefit be prioritized.. in patients with type 2 diabetes with insufficient glycemic control and who have atherosclerotic CVD. Furthermore, the EMPA-REG OUTCOME study reported a 39% reduction in incident or worsening nephropathy\u003c/p\u003e\u003cp\u003ethat included doubling of serum creatinine (relative risk reduction, 44%) and renal-replacement therapy (relative risk reduction, 55%) in the empagliflozin group, while the CANVAS-Renal trial similarly reported\u003c/p\u003e\u003cp\u003ean impressive 40% reduction in the composite renal outcome (defined as a sustained 40% reduction in the rate of eGFR decline, need for renal replacement therapy, or death from renal causes).\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIn this study we tried to approve benefits of SGLT2I using in ESRD on hemodialysis patients on cardiovascular and hematologic effect and subsequently on prognosis.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eWe started daily Empagliflozin 10 mg in 17 hemodialysis patients, who are on intermittent hemodialysis with twice weekly sessions, in the hemodialysis unit at Aleppo university hospital, to evaluate cardiac and hematologic benefits after 9 months of treatment.\u003c/p\u003e\u003cp\u003eWe randomized the patients regardless of the cause of ESRD (Diabetes, FSGS, Analgesic nephropathy,), the age, the sex, the residual kidney function, and dialysis duration.\u003c/p\u003e\u003cp\u003eWe excluded patients who have urinary anomalies.\u003c/p\u003e\u003cp\u003eAt baseline and after 9 months, we did echocardiography to measure cardiac parameters (left ventricular ejection fraction {EF%} and Interventricular septum diameter{IVSD}), and hemoglobin levels to all participants in our study.\u003c/p\u003e\u003cp\u003ePatients were prospectively monitored through 9 months to check benefits and possible side effects of the treatment.\u003c/p\u003e\u003cp\u003eWe analyzed the results, and did statistical study and analyzing charts by IBM SPSS program version 18.\u003c/p\u003e\u003cp\u003eA P. value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered as statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe randomized 17 patients on hemodialysis treatment (two sessions weekly), 64.7 % of them were male and 35.3% were female. There ages ranges from 22 years old to 75.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e patient\u0026rsquo;s characters and treatment outcomes\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eMonth 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eMonth 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Month 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Month \u003cspan dir=\"RTL\"\u003e9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eSEX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eHemoglobin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eHemoglobin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eIVSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEF%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eIVSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEF%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e12.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe causes of chronic kidney disease in participants were: diabetes (23.5%), GN (29.4%), HTN (29.4%), and analgesic nephropathy (23.5%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;Table 2 shows the mean and standard deviation of variables values before and after treatment\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"545\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eMEAN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eNUMBER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eHemoglobin before treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eHemoglobin after treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eEjection fraction before treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e53.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e12.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eEjection fraction after treatment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e56.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eIVSD before treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eIVSD after treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003cstrong\u003eTable 3\u003c/strong\u003e shows the mean, standard deviation, and the p.value of paired differences of variables before and after treatment\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 413px;\"\u003e\n \u003cp\u003ePaired Differences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eSig. (2-tailed)\u003c/p\u003e\n \u003cp\u003ep.value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eStd. Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eStd. Error Mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e95% Confidence Interval of the Difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003ePair 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eHemoglobin before treatment -Hemoglobin after treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003cspan dir=\"RTL\"\u003e0\u003c/span\u003e.6824\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.6748\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.1637\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-1.0293-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-\u003cspan dir=\"RTL\"\u003e0\u003c/span\u003e.3354-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003ePair 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eEjection fraction before treatment - Ejection fraction after treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e-2.70588\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e7.48970\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.81652\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-6.55673-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.14497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.156\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003ePair 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eIVSD before treatment \u0026nbsp;- IVSD after treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.08059\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.08856\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.02148\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.03505\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.12612\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e0.002\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eAfter treatment with Empagliflozin 10 mg daily for 9 months, we noticed a significant improvement in the hemoglobin levels, as it increased by mean of 0.68 mg/dl (p.value 0.001), (Std.Deviation (0.67), with statistically significance, as the mean value before treatment was (9.27) mg/dl with standard deviation (1.91), While The mean value after treatment increased to (9.95) mg/dl with standard deviation (1.56). Fig1\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIn addition, The Ejection fraction of left ventricle increased by mean of 2.7 % after treatment. (p.value 0.15), (Std.Deviation (7.48)), with no statistically significance, as the mean value before treatment was (53.7%) with Std. Deviation (12.93), while it was after treatment (56.4%) with Std. Deviation (8.90). Fig2\u003c/li\u003e\n \u003cli\u003eAlso, the study approved an important reduction in the mean value of IVSD (interventricular septum diameter), as it reduced by mean of 0.08 cm (p.value 0.002), (Std.Deviation(0.088)), with statistically significance, as The mean value before treatment was (1.42cm), with Std. Deviation (0.34), while it was (1.34cm) with Std. Deviation (0.31) after treatment. Fig3\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Discussion","content":"\u003cp\u003eSodium glucose cotransporter protein subtype-2 (SGLT-2) in the renal\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eproximal convoluted tubule is blocked by SGLT-2 inhibitors, thereby increasing renal excretion of glucose. There are increased risks for genital mycotic infections and, rarely, urinary tract infections; thus patients\u0026nbsp;\u003c/p\u003e\n\u003cp\u003etaking these should be cautioned.\u003c/p\u003e\n\u003cp\u003eIn the EMPA-REG OUTCOME trial,\u0026nbsp;patients with T2DM and GFR greater than 90 to 45 ml/min/1.73 m2\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ewere recruited.\u0026nbsp; Empagliflozin was seen to reduce the risk for CV mortality, all-cause mortality, and hospitalization for congestive heart failure with favorable effects on weight, systolic blood pressure (BP), and serum\u0026nbsp;\u003c/p\u003e\n\u003cp\u003euric acid.\u0026nbsp;This is consistent with previous reports of SGLT-2 inhibitors on reducing CV and all-cause mortality.\u003c/p\u003e\n\u003cp\u003eEMPA-REG OUTCOME also reported a reduction in doubling of serum creatinine and renal\u0026nbsp;replacement therapy (RRT) while reducing progression to macroalbuminuria; however, the perceived renal benefits cannot be fully explained by the moderate reduction in HbA1c, BP, or serum uric acid. It has been postulated that SGLT-2 inhibitors decrease proximal tubular reabsorption of sodium that increases distal sodium delivery to the macula densa that in turns activates tubuloglomerular feedback, resulting in afferent vasodilatation and a reduction of hyperfiltration. There is a reduction in intraglomerular pressure, BP, blood glucose, and blood volume. In addition, the increase in ketone body metabolism is thought to induce an energy-efficient oxygen consumption state at the mitochondrial level that reduces hypoxic stress in the kidney, reducing renal progression of DN.\u003c/p\u003e\n\u003cp\u003eü\u0026nbsp;In our study, we found similar results as worldwide studies approved, about improving cardiac structure (improved diastolic function and reduced interventricular septum diameter, but there were no significant effect on left ventricular ejection fraction, in addition\u0026nbsp;giving empagliflozin in CKD patients on RRT had also positive results on hemoglobin levels (increased hemoglobin by 0.68g/dl after 9 months),\u0026nbsp;But The important difference in our study is that, our cohort was ESRD patients on renal replacement therapy. these results mean that, improvement in cardiac structure, function, and hemoglobin levels, was achieved until in more advanced CKD patients with lower eGFR value, so we recommend to do larger trials to advance evidence and approve the benefits\u003c/p\u003e\n\u003cp\u003eMain limitations were, The small number of patients, and Patients no adherence to treatment.\u003c/p\u003e\n\u003cp\u003eWe advise to use Sglt2i in ESRD patients in special cases (such as heart failure with reduced ejection fraction, left ventricular hypertrophy LVH, and as additional therapy for anemia).\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study is the first one, that studied the effects of Empagliflozin on cardiac structure, and hemoglobin levels on hemodialysis patients. Here, we approved that, using Empagliflozin had cardiac and hematologic benefits, as the majority of patients had higher hemoglobin levels, and less interventricular septum diameter(IVSD) on echocardiography after treatment with Empagliflozin, with no important side effects that limit the using of these drugs. These are promised results to be added to the medical literature.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eCompeting interests and funding:\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no competing interest regarding the publication of this paper, and\u0026nbsp;No funding was involved in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and accordance:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe protocol was approved by (Aleppo university hospital/university of Aleppo) in accordance with the guidelines and regulations\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e-minimizing harm to participants\u003c/p\u003e\n\u003cp\u003e-obtaining informed consent from research subjects\u003c/p\u003e\n\u003cp\u003e-protecting participant’s anonymity and confidentiality.\u003c/p\u003e\n\u003cp\u003e-avoiding deceptive practices in research.\u003c/p\u003e\n\u003cp\u003e-respecting the rights and dignity of research subjects\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was taken from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNot applicable in this manuscript\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll datasets generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr.Sami albitar did the general review, patients treatment and monitoring.\u003c/p\u003e\n\u003cp\u003eDr.Mohamad Kattan participated in patients treatment and did the information collection and writing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNote:\u003c/p\u003e\n\u003cp\u003eThe words beside the marker\u0026nbsp;ü\u0026nbsp; is the author’s words.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eJohn Feehally, DM, FRCP ,J\u0026uuml;rgen Floege, MD, FERA ,Marcello Tonelli, MD, SM, MSc, FRCPC ,Richard J. Johnson, MD , Comprehensive Clinical Nephrology SIXTH EDITION \u0026copy; 2019, Elsevier Inc, ISBN: 978-0-323-47909-7 E-ISBN: 978-0-323-54719-2, 2015v1.0, 913,935,938,378,389,390\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chronic kidney disease, Ejection fraction, Hemoglobin, Interventricular septum diameter, Sodium glucose transporter 2 inhibitors","lastPublishedDoi":"10.21203/rs.3.rs-7643324/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7643324/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u003c/p\u003e\n\u003cp\u003eSeveral risk factors in chronic kidney disease (CKD) patients cause mortality; cardiovascular risk is the most important one.\u003c/p\u003e\n\u003cp\u003eSo, new protective treatments have to be added to the management of CKD patients; the most important one are renin angiotensin aldosterone system inhibitors (RAASI), but the latest one are sodium glucose transporter 2 inhibitors (SGLT2i).\u003c/p\u003e\n\u003cp\u003eHere in this study, we tried to approve cardiac and hematologic benefits of Empagliflozine using in end stage renal disease (ESRD) on renal replacement therapy (RRT) patients.\u003c/p\u003e\n\u003cp\u003eMethods:\u003c/p\u003e\n\u003cp\u003ewe started Empagliflozin 10 mg for 9 months in 17 hemodialysis patients. Echocardiography and serum hemoglobin to measure cardiac parameters (interventricular septum diameter {IVSD} and ejection fraction{EF%}) and serum hemoglobin (HG) levels were done at baseline and after 9 months.\u003c/p\u003e\n\u003cp\u003eWe included diabetic and non-diabetic patients in our study.\u003c/p\u003e\n\u003cp\u003ePatients with urinary anomalies were excluded.\u003c/p\u003e\n\u003cp\u003eStatistical analysis was done to the results by IBM SPSS program to evaluate the benefits.\u003c/p\u003e\n\u003cp\u003eResults:\u003c/p\u003e\n\u003cp\u003eWe included 17 participants, 64.7 % of them were male and 35.3% were female. There ages ranges from 22 years old to 75. Results declared cardiac benefits, as interventricular septum diameter(IVSD) was reduced by mean of 0.08 cm (p.value 0.002), (Std.Deviation(0.088), and increased left ventricular ejection fraction (EF%) by mean of 2.7 % after treatment. (p.value 0.15), (Std.Deviation (7.48), and hematologic benefits, as hemoglobin increased by mean of 0.68 mg/dl (p.value 0.001), (Std.Deviation (0.67), with no important side effects.\u003c/p\u003e\n\u003cp\u003eConclusion:\u003c/p\u003e\n\u003cp\u003eWe concluded that, using empagliflozin in hemodialysis patients, improved cardiac function and increased hemoglobin levels with statistically significance, and may improve prognosis and quality of life.\u003c/p\u003e","manuscriptTitle":"Effects of Empagliflozin in chronic kidney disease on hemodialysis patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-17 10:00:51","doi":"10.21203/rs.3.rs-7643324/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa25cb43-249e-46ee-95f8-d47699440580","owner":[],"postedDate":"November 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-17T07:24:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-17 10:00:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7643324","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7643324","identity":"rs-7643324","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}