Management of SGLT2 Inhibitors in Acute Kidney Injury

Guideline-Based Recommendations for Discontinuation

The KDIGO guidelines recommend withholding SGLT2 inhibitors during critical medical illness when patients are at greater risk for ketosis, in patients with prolonged fasting or reduced oral intake, during surgery requiring bowel preparation or extended hospitalization, and in acute illness with fluid losses 1
The Kidney Disease: Improving Global Outcomes (KDIGO) 2022 guidelines state it is reasonable to withhold SGLT2 inhibitors during critical medical illness, prolonged fasting, surgery, and acute illness with fluid losses 1

The combination of AKI and SGLT2 inhibitor-induced volume depletion can worsen kidney injury, particularly in patients who are hypovolemic and more susceptible to further renal function deterioration 1

SGLT2 inhibitors can be resumed after the patient is eating and drinking normally, has complete resolution of the acute illness that precipitated the AKI, has adequate volume status and hemodynamic stability, and has verified kidney function stabilization or improvement 1
The Kidney International guidelines recommend resuming SGLT2 inhibitors only after the patient has recovered from the acute illness, has adequate volume status, and has stable kidney function 1

Once restarted following AKI recovery, SGLT2 inhibitors can be continued even if eGFR subsequently falls below 20 mL/min/1.73 m², unless kidney replacement therapy is initiated, as stated by the Kidney International guidelines 1
A reversible decrease in eGFR with SGLT2 inhibitor use is generally not an indication to discontinue therapy in stable chronic kidney disease, according to the Kidney International guidelines 1

The Kidney International guidelines warn against confusing the expected initial eGFR dip with AKI, and against continuing SGLT2 inhibitors during acute illness "because they're kidney protective" 1
The Kidney International guidelines recommend reducing concomitant diuretics before initiating SGLT2 inhibitors in patients at risk for volume depletion, and educating patients about "sick day protocols" to temporarily withhold during illness, maintain hydration, and seek medical attention early 1