Management of Patients with Decreased Kidney Function

Introduction to SGLT2 Inhibitors

The American College of Cardiology suggests that benefits of SGLT2 inhibitors in patients with advanced renal dysfunction remain less clear, and their glucosuric effects are attenuated in those with lower eGFRs 1
The American Journal of Kidney Diseases reports that the DAPA-CKD trial showed benefits for dapagliflozin in patients with CKD with and without diabetes, indicating potential benefits of SGLT2 inhibitors in certain non-diabetic populations 2

The American College of Cardiology notes that empagliflozin may cause temporary worsening of renal function during the first year of use, posing a risk of acute kidney injury 1
The American Diabetes Association and KDIGO consensus report do not recommend empagliflozin use with eGFR <45 mL/min/1.73 m², due to lack of efficacy and safety concerns in patients with severe renal impairment 3

The American College of Cardiology recommends considering other guideline-directed medical therapy options before SGLT2 inhibitors if eGFR <45 mL/min/1.73 m² for heart failure with reduced ejection fraction 1
The American Journal of Kidney Diseases suggests focusing on optimized supportive care including blood pressure management with ACE inhibitors or ARBs for patients with proteinuria >0.5 g/d for chronic kidney disease management 2
The American Diabetes Association recommends against initiating empagliflozin in patients with eGFR <45 mL/min/1.73 m², and discontinuing it if eGFR falls persistently below this threshold, due to decreased efficacy and increased risk of adverse effects 3

The glucose-lowering effect of empagliflozin is dependent on renal function and is minimal in ESRD, making it ineffective in patients with end-stage renal disease 3
The EMPA-REG OUTCOME trial excluded patients with ESRD, only including those with eGFR ≥30 mL/min/1.73 m², highlighting the concern for empagliflozin's efficacy and safety in advanced renal disease 4