#3691 Successful use of glucagon-like peptide-1 receptor agonists (GLP1-RA) in a patient with obesity and diabetic kidney disease under peritoneal dialysis: a Case Report

Abstract Background Semaglutide is a glucagon-like peptide-1 receptor agonists (GLP1-RA), which showed a significant effect in slowing renal progression and reducing cardiovascular risk in patients affected by obesity and diabetic kidney disease in the recent FLOW trial. However, there is a scarcity of observations regarding the effects of semaglutide in patients undergoing peritoneal dialysis (PD). Methods This is a case report to describe the first use of semaglutide for six months in a diabetic patient under continuous ambulatory peritoneal dialysis (CAPD) who was ineligible for kidney transplantation due to obesity. Clinical case A 59-year-old male patient with type 2 diabetes following intensive insulin therapy, treated in the last two years with CAPD, had been considered ineligible to kidney transplantation due to obesity. The hypocaloric diet had always been ineffective due to low patient compliance. We therefore chose to use semi-injective semaglutide to allow a weight loss sufficient to be listed for kidney transplantation. Body weight was 97.5 kg (BMI 33.7 Kg/m2) and blood pressure (BP) 150/90 mmHg. The patient was treated with insulin 43 U/day (18 U Aspart and 25 U Degludec), along with furosemide 250 mg, amlodipine 10 mg, eplerenone 50 mg, bisoprolol 2.5 mg/day, clopidogrel/aspirin 70/100 mg, omega−3 fatty acids 3000 mg and atorvastatin 40 mg (Fig. 1). Residual diuresis was 1000 ml/24 h and residual kidney function was 5 ml/min. The CAPD schedule consisted of two 5 h dwells of 2 L of 1.36% glucose and a 14 h dwell of 2 L icodextrin. On 1st March 2024, the patient began subcutaneous semaglutide with the following schedule: 0.25 mg/week for the first 4 weeks then uptitrated to 0.5 mg/week if tolerated. After 4 weeks, the patient achieved a weight loss of 2.8 kg. The patient experienced nausea; however, since this adverse effect was well tolerated, the semaglutide dose was increased to 0.5 mg/day. From week-4 to week-16, a body weight reduction from 94.7 kg to 86.5 kg was observed. The weight loss was associated with a reduction in glycated haemoglobin from 7.6% to 6.1% with a remarkable reduction in daily insulin requirement, from 43 to 15 U/day. Similarly, the dependent effect on BP control led to the discontinuation of amlodipine and eplerenone and the decrease in daily furosemide dose from 250 to 50 mg. No significant change in residual diuresis and weekly KtV was observed. Therefore, dialysis prescription could remain unmodified. The BMI goal, that is a BMI value allowing inclusion in the list for KTR, was achieved within 16 weeks. Due to volume depletion episodes related to the high temperature in Naples (Southern Italy) occurring in the July–August period, the semaglutide dose was reduced to 0.25 mg/week to allow a higher intake of nutrients and salt. This adjustment resulted in a slight increase in BW (up to 87.5 kg at 24 weeks) coupled with improvement in gastric symptoms (Fig. 1). The patient was successfully considered suitable for kidney transplantation. Conclusions This case report highlights the positive effects of GLP1-RA in an obese patient with diabetic kidney disease undergoing CAPD. After six months of semaglutide therapy, the patient achieved notable weight loss and reduced his daily insulin dosage by 50%. These improvements made him eligible for kidney transplantation listing. The significance of weight loss in patients receiving PD is further amplified by the fact that these patients cannot undergo bariatric surgery unless they switched to extracorporeal dialysis. Beyond weight loss, we observed a remarkable amelioration in BP control, likely due to reduced overhydration and insulin resistance, improving his cardiovascular risk. Regarding side effects, the patient experienced mild gastric symptoms during semaglutide therapy; however, these symptoms were less tolerated during the hot season, prompting a need for dose reduction to prevent volume depletion. In conclusion, GLP1-RAs may help improve metabolic control in patients with obesity and diabetes treated by PD potentially making kidney transplantation feasible. GLP1-RAs is well tolerated, though a careful monitoring is required.