SGLT2 Inhibitors for Type 2 Diabetes with Chronic Kidney Disease

Introduction to SGLT2 Inhibitors

The American Diabetes Association and the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend the use of SGLT2 inhibitors, such as canagliflozin, dapagliflozin, and empagliflozin, for patients with type 2 diabetes and chronic kidney disease (CKD), as they have proven kidney and cardiovascular benefits 1, 2

For a patient with type 2 diabetes and CKD, the American College of Cardiology recommends initiating dapagliflozin 10 mg daily if eGFR ≥20 mL/min/1.73 m², as it has the strongest evidence from the DAPA-CKD trial specifically designed for kidney outcomes in both diabetic and non-diabetic CKD patients 1, 3
Dapagliflozin demonstrated a 39% risk reduction in the primary kidney endpoint (≥50% eGFR decline, ESKD, or renal/CV death) in the DAPA-CKD trial, which specifically enrolled CKD patients with eGFR 25-75 mL/min/1.73 m² and albuminuria ≥200 mg/g 1, 3
The DAPA-CKD trial showed a 56% risk reduction for the composite of sustained eGFR decline ≥50%, ESKD, or death from renal causes (HR 0.56, 95% CI 0.45-0.68) 3

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend initiating SGLT2 inhibitor when eGFR ≥20 mL/min/1.73 m², regardless of current HbA1c or glycemic control needs, as benefits are independent of glucose-lowering effects 1, 2, 3
High priority initiation is recommended for patients with albuminuria ≥200 mg/g (≥20 mg/mmol) 2, 4

The American Heart Association recommends assessing volume status and correcting volume depletion before initiating SGLT2 inhibitors, particularly in patients on loop diuretics 1, 2
The European Association for the Study of Diabetes recommends checking baseline eGFR and albuminuria (spot urine ACR) before initiating SGLT2 inhibitors 1, 2

The American Diabetes Association recommends not withholding SGLT2 inhibitors based on HbA1c being at goal - the kidney and cardiovascular benefits are independent of glucose-lowering effects 1, 2
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend not discontinuing SGLT2 inhibitors when eGFR falls below 20 mL/min/1.73 m² if already initiated - continue until dialysis or transplant 2, 4

The American College of Cardiology recommends combining SGLT2 inhibitors with RAS inhibitors (ACE inhibitors or ARBs) - over 99% of CREDENCE participants were on background RAS blockade 3
The European Society of Cardiology recommends combining SGLT2 inhibitors with nonsteroidal mineralocorticoid receptor antagonists (finerenone) with additive cardiovascular benefits 4