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American Journal of Physiology-Cell PhysiologyPhysiologyPeer-reviewed journal article

Empagliflozin targets a renal neuro-epithelial-immune axis in heart failure

Jennifer N. CoelhoiD, Livia C. SimoneteiD, João Carlos Ribeiro-SilvaiD, Erika F. Jesus, Andreia BoaroiD, Flavia L. MartinsiD, José Wilson do Nascimento CorrêaiD, Larissa Ferreira dos SantosiD, Danúbia Silva dos SantosiD, Ednei Luiz AntônioiD, Raphael E. SzawkaiD, Andrey Jorge SerraiD, Adriana C. C. GirardiiD

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In-depth summary

Claude Sonnet 4.6 · xhigh effort · 8 Nov 2026 · from the full text of version 1 (2 Apr 2026) · CC BY 4.0

Empagliflozin lowered renal norepinephrine by about 50% in rats with heart failure, independent of intrarenal renin-angiotensin activity, and shifted kidney macrophages toward a reparative phenotype.

SGLT2 inhibitors protect the kidney in heart failure, but whether this involves renal neurohormonal activity is unclear. This work measures renal sympathetic and renin-angiotensin readouts together with macrophage polarization and proximal tubule cell responses, to separate these routes.

Key results

  1. ShownIn rats with post-infarction heart failure, empagliflozin lowered urinary norepinephrine excretion and renal cortical norepinephrine content, which were elevated relative to sham animals.

    Urinary NE excretion fell by approximately 50% and renal cortical NE by about 50% with empagliflozin versus untreated HF (urinary NE n=8-9 rats per group). Measured by competitive ELISA and HPLC with electrochemical detection. · EMPA reduces urinary and cortical NE in HF rats…; Determination of renal Angiotensin II…; Determination of kidney NE concentration; Figure legends

  2. ShownHeart failure raised renal renin expression and Ang II, and empagliflozin left both unchanged while improving congestion and limiting GFR decline, so the sympatholytic effect appears separate from intrarenal RAS modulation.

    HF raised renal renin expression and Ang II, with no EMPA effect; Agt stayed low, and Ace, Ace2, Agtr1 and Ang-(1-7) were unchanged (n=7-10 per group). FAC was 33±1% in HF vs 64±1% in sham (P<0.001, n=32 per group). · EMPA reduces congestion and preserves GFR in HF…; Figure legends

  3. SuggestedEmpagliflozin did not change total renal macrophage abundance but moved the polarization markers from M1-like toward M2-like in heart failure kidneys.

    CD68 abundance was higher in HF than sham with no EMPA effect (n=9 per group). M1 markers (Tnf, Nos2, Ccr2, Il-6) fell and M2 markers (Arg1, Mrc1, Cd163) rose (n=7-10). CD68+/CD206+ cells per field: 0.7 ± 0.3 (HF) vs 4.7 ± 1.2 (HF+EMPA), P<0.03, n=3 rats/group. · EMPA promotes a phenotypic shift from…; Figure legends

  4. ShownIn HK-2 proximal tubule cells, norepinephrine induced SGLT2 and IL-6, and co-treatment with empagliflozin prevented both responses.

    NE (1 µM, 48h) raised IL-6 mRNA and secreted IL-6 protein by approximately 50%; EMPA (1 µM) co-treatment kept IL-6 at control levels (***P<0.001, ****P<0.0001). NE-induced SGLT2 mRNA was abrogated by EMPA (n=6). · EMPA reduces urinary and cortical NE in HF rats…; EMPA antagonizes NE-induced IL-6 and TNF-α…; Cell culture; Figure legends

  5. ShownEmpagliflozin had no direct effect on THP-1 macrophage polarization, which fits an indirect effect through the renal microenvironment.

    EMPA at 1 or 10 µM left Tnf and Mrc1 unchanged in PMA-activated cells, did not alter IFN-γ/LPS-induced Tnf, and did not alter IL-4-induced Mrc1; data from five independent experiments performed in duplicate. · EMPA does not directly influence macrophage…; Cell culture; Figure legends

Methods, data and reproducibility

Male rats with myocardial infarction-induced heart failure or sham surgery received empagliflozin chow for four weeks, followed by renal RAS, norepinephrine and macrophage readouts. THP-1 and HK-2 cell experiments tested direct drug effects.

  • Male Wistar rats, heart failure (LAD ligation) or sham, randomized to empagliflozin chow (300 mg/kg) or untreated for four weeks · rat (Wistar) · n = HF n=32, sham n=32 (panel n varies, 3-17 per group)
  • THP-1 monocyte-derived macrophages, M0/M1/M2 conditions, empagliflozin 1 or 10 µM · human · n = five independent experiments in duplicate
  • HK-2 proximal tubule cells treated with vehicle, NE, EMPA or NE+EMPA · human · n = n=6 (SGLT2 mRNA); nine independent experiments (IL-6 ELISA)
Methods & tools
Echocardiography (Sonos 5500), FITC-sinistrin transcutaneous GFR (MediBeacon, MB Studio 3), ELISA (BNP, Ang II, Ang-(1-7), IL-6, urinary NE), HPLC with electrochemical detection (tissue NE), CD68 immunohistochemistry, CD68/CD206 dual immunofluorescence, RT-qPCR (2^-ΔΔCT, TaqMan, SYBR Green), BestKeeper, ImageJ, Two-way ANOVA with Tukey post hoc test
Reproducibility gaps
Data available from the corresponding author upon reasonable request; no analysis code or public repository reported.
Limitations (4)
  • Renal sympathetic nerve activity and renal NE spillover were not measured directly; sympathetic tone was inferred from urinary and cortical NE, which also reflect release, reuptake, metabolism and excretion. · stated by the authors
  • The present data cannot prove a causal chain from reduced sympathetic activity to lower tubular cytokine output to macrophage repolarization; the indirect mechanism rests on concordant observations. · stated by the authors
  • The CD68/CD206 immunofluorescence comparison used only 3 rats per group and was quantified in HF animals only, so the M2 shift rests mainly on mRNA markers. · noted in this summary
  • Only male rats in one myocardial infarction model were studied, and the in vitro NE exposure (1 µM) was not matched to measured tissue concentrations. · noted in this summary

Read this if you study cardiorenal mechanisms of SGLT2 inhibitors and want rat and cell-line evidence linking renal norepinephrine, tubular IL-6 and macrophage polarization.

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Abstract

BackgroundPersistent neurohormonal activation is a key driver of maladaptive remodeling and disease progression in heart failure (HF). Sodium-glucose cotransporter 2 inhibitors (SGLT2is) confer robust renoprotective effects in HF; however, the extent to which these benefits involve modulation of renal neurohormonal activity remains unclear. We hypothesized that SGLT2i-mediated renoprotection in HF is associated with attenuation of excessive renal neurohormonal activation. MethodsMale rats with myocardial infarction-induced HF and sham controls were fed standard chow or chow containing empagliflozin (EMPA, 300 mg/kg) for four weeks, followed by assessment of renal inflammatory and neurohormonal markers. Parallel in vitro studies in THP-1 macrophages and HK-2 proximal tubule cells evaluated the direct effects of EMPA on norepinephrine (NE)-dependent tubular inflammatory signaling. ResultsHF rats displayed higher renal cortical renin gene expression and angiotensin II concentrations, which remained unaffected by EMPA. Conversely, EMPA normalized the elevated urinary NE excretion and renal cortical NE content observed in HF rats. Given the inflammatory role of sympathetic hyperactivity, we assessed renal macrophage polarization. EMPA-treated HF rats showed reduced expression of pro-inflammatory markers (Tnf, Ccr2, Nos2, Il-6) and increased expression of markers associated with a reparative macrophage profile (Arg1, Mrc1, CD163), supported by higher CD206 macrophages in kidney sections. While EMPA did not directly alter THP-1 macrophage activation in vitro, it significantly reduced NE-induced SGLT2 expression and interleukin-6 (IL-6) release by HK-2 human proximal tubule epithelial cells. ConclusionThese findings support a model in which SGLT2 inhibitors confer renoprotection in HF by suppressing renal sympathetic hyperactivity, independently of the intrarenal renin-angiotensin system, thereby disrupting a maladaptive renal neuro-epithelial-immune axis and promoting a reparative macrophage phenotype. CLINICAL PERSPECTIVE Whats new?O_LIThis study identifies a renal neuro-epithelial-immune axis underlying empagliflozin-mediated renoprotection in heart failure. C_LIO_LIEmpagliflozin reduces renal cortical and urinary norepinephrine levels in heart failure without altering intrarenal renin-angiotensin system activity, revealing a distinct neurohumoral target of SGLT2 inhibition. C_LIO_LIThis sympatholytic effect is associated with a shift in renal macrophages toward a reparative (M2) phenotype, without changes in total macrophage abundance. C_LIO_LIEmpagliflozin blocks norepinephrine-induced SGLT2 upregulation, limiting proximal tubular glucose reabsorption and IL-6 production, and linking sympathetic signaling to renal inflammation. C_LI What are the clinical implications?O_LIOur findings provide a mechanistic basis for the additive cardiorenal benefits of SGLT2 inhibitors in heart failure, beyond conventional RAS-directed therapies. C_LIO_LITargeting renal sympathetic-driven inflammation may help preserve kidney function and attenuate the progression of cardiorenal syndrome. C_LIO_LISuppression of a renal neuroinflammatory pathway may help explain the early and sustained benefits of SGLT2 inhibitors across heart failure phenotypes, including nondiabetic patients. C_LI

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