SGLT2 Inhibitor Use in Patients with Chronic Kidney Disease

Guideline Recommendations

The Kidney Disease: Improving Global Outcomes (KDIGO) 2022 guideline recommends initiation of an SGLT2 inhibitor for patients with type 2 diabetes and chronic kidney disease who have an estimated glomerular filtration rate (eGFR) ≥20 ml/min/1.73 m² 1
The American Diabetes Association (ADA) and KDIGO 2022 guidelines have updated recommendations to allow SGLT2 inhibitor initiation at lower eGFR thresholds than the FDA label indicates, with the strongest evidence for initiation in patients with concomitant albuminuria or heart failure 1, 2

Glucose-lowering efficacy of SGLT2 inhibitors decreases with declining renal function, but kidney and cardiovascular benefits may be preserved 3
SGLT2 inhibitors can be continued at lower levels of eGFR according to recent guidelines, with monitoring for volume depletion, especially in patients with renal impairment 2, 3
Implement risk mitigation strategies for potential side effects including genital mycotic infections and ketoacidosis 2, 3

Consider alternative SGLT2 inhibitors with proven efficacy at lower eGFR (e.g., dapagliflozin) for patients with eGFR <45 mL/min/1.73 m² 3
The initial eGFR dip of 3-5 mL/min/1.73 m² in the first 4 weeks of therapy is expected and generally not a reason to discontinue therapy 4

The American Diabetes Association recommends SGLT2 inhibitors for patients with eGFR 20-60 mL/min/1.73 m² and/or albuminuria 5
For advanced CKD (eGFR <30 mL/min/1.73 m²), GLP-1 receptor agonists are preferred for glycemic management due to lower hypoglycemia risk, according to the American Diabetes Association 5

Patients with eGFR 20-44 mL/min/1.73 m² may be considered for Jardiance initiation based on guidelines, especially with albuminuria or heart failure, although this is off-label use 5