Can you use a SGLT2 (sodium-glucose linked transporter 2) inhibitor in patients with stage 3b chronic kidney disease (CKD)?

SGLT2 Inhibitors in Stage 3b Chronic Kidney Disease

Yes, SGLT2 inhibitors can and should be used in patients with stage 3b chronic kidney disease (eGFR 30-44 ml/min/1.73m²) for their proven kidney and cardiovascular benefits. 1 According to the most recent 2022 KDIGO guidelines, SGLT2 inhibitors are recommended for patients with type 2 diabetes, CKD, and an eGFR ≥20 ml/min/1.73m², which includes stage 3b CKD.

Efficacy in Stage 3b CKD

SGLT2 inhibitors provide significant benefits in patients with stage 3b CKD:

• Kidney protection: They slow CKD progression and reduce risk of kidney failure
• Cardiovascular protection: They reduce major adverse cardiovascular events
• Mortality benefit: They improve overall survival

While the glucose-lowering effect may be somewhat reduced at lower eGFR levels, the kidney and cardiovascular protective effects remain robust even in advanced CKD 2.

Dosing Considerations

When using SGLT2 inhibitors in stage 3b CKD:

• Canagliflozin: Maximum 100 mg daily
• Dapagliflozin: 10 mg daily
• Empagliflozin: 10 mg daily
• Ertugliflozin: Not recommended with eGFR <45 ml/min/1.73m² 1

Monitoring and Management

When initiating SGLT2 inhibitors in stage 3b CKD:

1. Expect an initial eGFR drop:

   • A reversible decrease in eGFR upon starting therapy is common
   • This is generally not a reason to discontinue the medication 1

2. Volume status management:

   • Consider reducing diuretic doses before starting SGLT2i if patient is at risk for hypovolemia
   • Educate patients about symptoms of volume depletion
   • Follow up to assess volume status after initiation 1

3. Continuation at lower eGFR:

   • Once initiated, SGLT2 inhibitors can be continued even if eGFR falls below 20 ml/min/1.73m²
   • Only discontinue if not tolerated or if kidney replacement therapy is initiated 1

Special Precautions

Key safety considerations include:

• Withhold during high-risk periods:

  • Prolonged fasting
  • Surgery
  • Critical illness (when ketosis risk is higher) 1

• Monitor for adverse effects:

  • Genital mycotic infections (more common in women)
  • Euglycemic diabetic ketoacidosis (especially in insulin users)
  • Volume depletion 1

Recent Evidence

A 2023 population-based study demonstrated that SGLT2 inhibitors in patients with advanced CKD (stages 3B-5) significantly:

• Reduced kidney-related adverse events (7.7% vs 24.1%)
• Reduced major adverse cardiovascular events (9.6% vs 15.1%)
• Improved eGFR (0.4 ± 9.3 vs -5.5 ± 10.6 ml/min/1.73m²)
• Improved glycemic control with reduced insulin requirements 3

Implementation Algorithm

1. Assess baseline status:

   • Confirm eGFR is ≥20 ml/min/1.73m²
   • Evaluate volume status and diuretic use
   • Review current diabetes medications

2. Select appropriate SGLT2 inhibitor:

   • Choose agent with documented kidney/CV benefits
   • Consider eGFR-specific dosing restrictions

3. Adjust concomitant medications:

   • Consider reducing diuretic dose if volume depletion risk
   • Adjust other glucose-lowering medications if hypoglycemia risk

4. Patient education:

   • Sick day management (withhold during illness)
   • Volume depletion symptoms
   • Genital hygiene to reduce infection risk

5. Follow-up monitoring:

   • Assess volume status
   • Monitor kidney function (expect initial eGFR dip)
   • Check for adverse effects

Conclusion

The 2022 KDIGO guidelines strongly support using SGLT2 inhibitors in patients with stage 3b CKD (eGFR 30-44 ml/min/1.73m²) with a Grade 1A recommendation 1. The benefits extend beyond glycemic control to include significant kidney and cardiovascular protection. While some dose adjustments may be needed, the evidence clearly supports their use in this population.