What is the approach to using Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors in patients with impaired renal function, specifically those with a Glomerular Filtration Rate (GFR) of 20?

From the Guidelines

SGLT2 inhibitors can be used in patients with a GFR of 20 ml/min/1.73m², as they provide cardiorenal benefits and reduce CKD progression and cardiovascular events, as recommended by the 2025 guidelines 1. The use of SGLT2 inhibitors in patients with impaired renal function, specifically those with a GFR of 20, is supported by recent evidence.

• Key considerations for using SGLT2 inhibitors in patients with a GFR of 20 include:
  • Selecting specific agents based on comorbidity and CKD stage
  • Monitoring for adverse effects, such as volume depletion, hypotension, and acute kidney injury
  • Temporarily discontinuing the medication during acute illness ("sick days") to prevent complications
  • Regularly monitoring renal function, electrolytes, and volume status According to the 2025 guidelines, SGLT2 inhibitors can be used in individuals with eGFR as low as 20 mL/min/1.73 m², with a recommendation to reduce CKD progression and cardiovascular events in people with type 2 diabetes and CKD 1. Additionally, the KDIGO 2022 clinical practice guideline recommends treating patients with type 2 diabetes, CKD, and an eGFR ≥20 ml/min per 1.73 m² with an SGLT2i for kidney and cardiovascular protection 1. It is essential to prioritize the single most recent and highest quality study, which in this case is the 2025 guideline 1, when making a definitive recommendation.
• The benefits of SGLT2 inhibitors in patients with a GFR of 20 include:
  • Reduced intraglomerular pressure
  • Decreased inflammation
  • Improved cardiac energetics
  • Cardiorenal benefits independent of glycosuria Overall, the use of SGLT2 inhibitors in patients with a GFR of 20 is recommended, with careful consideration of the patient's individual needs and close monitoring for potential adverse effects, as supported by the most recent and highest quality evidence 1.

From the Research

Approach to Using SGLT2 Inhibitors in Patients with Impaired Renal Function

• The use of Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors in patients with impaired renal function, specifically those with a Glomerular Filtration Rate (GFR) of 20, requires careful consideration of the potential benefits and risks.
• Studies have shown that SGLT2 inhibitors can slow the progression of chronic kidney disease and reduce the risk of cardiovascular events in patients with type 2 diabetes mellitus 2, 3, 4, 5, 6.
• However, the efficacy and safety of SGLT2 inhibitors in patients with severe renal impairment (GFR <30) are not well established, and their use in this population is not recommended unless the potential benefits outweigh the risks.

Renal Effects of SGLT2 Inhibitors

• SGLT2 inhibitors have been shown to reduce the glomerular filtration rate (GFR) in patients with type 2 diabetes mellitus, which may be beneficial in slowing the progression of chronic kidney disease 4, 5.
• The renal effects of SGLT2 inhibitors are thought to be mediated by the inhibition of sodium and glucose reabsorption in the proximal tubules, leading to increased renal glucose and sodium excretion 2, 5.
• Long-term treatment with SGLT2 inhibitors has been shown to slow the decline in GFR and reduce the risk of renal events in patients with type 2 diabetes mellitus 3, 6.

Clinical Considerations

• The decision to use SGLT2 inhibitors in patients with impaired renal function should be based on individual patient factors, including the severity of renal impairment, the presence of other comorbidities, and the potential benefits and risks of treatment.
• Patients with severe renal impairment (GFR <30) should be closely monitored for signs of worsening renal function, and the dose of SGLT2 inhibitors should be adjusted accordingly.
• The use of SGLT2 inhibitors in patients with impaired renal function should be guided by clinical practice guidelines and the results of ongoing clinical trials.