What are the considerations for using Jardiance (empagliflozin) in patients with Chronic Kidney Disease (CKD)?

Jardiance (Empagliflozin) in Chronic Kidney Disease: Clinical Considerations

For patients with chronic kidney disease, empagliflozin is strongly recommended to reduce CKD progression and cardiovascular events in patients with an eGFR ≥20 mL/min/1.73 m² regardless of albuminuria status. 1, 2

Efficacy in CKD

Empagliflozin provides significant benefits for patients with CKD:

• Reduces risk of kidney disease progression by 28% regardless of diabetes status 2
• Slows the rate of eGFR decline by 50% after initial hemodynamic dip 3
• Decreases risk of hospitalization from any cause by 14% 2
• Benefits extend across all CKD etiologies, including diabetic and non-diabetic kidney disease 4

Dosing Guidelines

• Initiation threshold: Can be started in patients with eGFR ≥20 mL/min/1.73 m² 1, 5
• Continuation: Can be continued even if eGFR falls below initiation threshold until dialysis or transplant 1
• Dosing: 10 mg once daily 2
• Monitoring: Assess renal function before initiation and periodically thereafter 6

Mechanism of Renal Protection

Empagliflozin provides renoprotection through multiple mechanisms:

• Reduces intraglomerular pressure by affecting tubuloglomerular feedback 1
• Decreases renal cortical hypoxia by reducing glucose reabsorption burden 1
• Improves structure and function of kidneys damaged by diabetes 1
• Reduces albuminuria and oxidative stress in the kidney 5

Safety Considerations

Volume Status

• May cause intravascular volume contraction 6
• Consider patient's volume status, especially when used with diuretics 1
• Monitor for signs of hypovolemia, particularly during initiation 1

Acute Kidney Injury Risk

• Temporarily discontinue during periods of reduced oral intake or fluid losses 6
• Use caution in patients with risk factors for acute kidney injury 6

Metabolic Considerations

• Risk of euglycemic ketoacidosis, especially in insulin-dependent patients 6
• Consider pausing during acute illness or stressors 1
• Maintain at least low-dose insulin in insulin-requiring individuals 1

Infections

• Increased risk of genital mycotic infections (6% vs 1% with placebo) 1
• Monitor for urinary tract infections, including urosepsis and pyelonephritis 6

Special Populations

Diabetic CKD

• Empagliflozin reduces cardiovascular events and slows CKD progression in diabetic patients 1
• Benefits are independent of glucose-lowering effects 1

Non-diabetic CKD

• Recent evidence from EMPA-KIDNEY trial shows similar benefits in non-diabetic CKD patients 2, 4
• Effective across various etiologies of CKD, including glomerular disease and hypertensive nephropathy 4

Low Albuminuria

• Benefits extend to patients with minimal albuminuria 3
• Relative reduction in chronic eGFR slope was actually greater (86%) in patients with uACR <30 mg/g 3

Practical Implementation

1. Before starting: Assess volume status, renal function, and risk factors for adverse effects
2. Patient education: Explain potential side effects, especially genital infections and signs of volume depletion
3. Sick day protocol: Advise temporary discontinuation during acute illness or 3-4 days before elective procedures 1
4. Monitoring: Check renal function at baseline, after 2-4 weeks, and then every 3-6 months 5

Empagliflozin represents a significant advance in CKD management, with benefits extending beyond glycemic control to include direct kidney and cardiovascular protection across a wide spectrum of kidney function and disease etiologies.