How should a patient with a family history of kidney failure, type 2 diabetes mellitus, and African American ethnicity, taking a SGLT2 inhibitor, monitor and manage her renal function?

Managing Renal Function in an African American Patient with Type 2 Diabetes on SGLT2 Inhibitor

SGLT2 inhibitors are strongly recommended for patients with type 2 diabetes and chronic kidney disease as they reduce CKD progression and cardiovascular events, and should be continued in this patient with family history of kidney failure, especially given her African American ethnicity which increases risk. 1

Risk Assessment and Monitoring

• African American ethnicity and type 2 diabetes are significant risk factors for chronic kidney disease (CKD), requiring vigilant monitoring 1
• Regular assessment of renal function through eGFR and urine albumin-to-creatinine ratio (ACR) should be performed at least annually if normal, and more frequently if abnormalities are detected 1
• For patients with normal kidney function, screening should include:
  • Spot urine ACR measurement
  • eGFR calculation
  • These tests should be repeated to confirm persistence of abnormalities for at least 3 months before diagnosing CKD 1

Benefits of SGLT2 Inhibitor Therapy

• SGLT2 inhibitors provide significant renoprotection in patients with type 2 diabetes 1
• These medications are recommended for patients with eGFR ≥20 mL/min/1.73 m² to reduce CKD progression and cardiovascular events 1
• SGLT2 inhibitors can be continued even if eGFR declines below the threshold for initiation 1
• A transient decrease in eGFR upon starting an SGLT2 inhibitor is expected and not a reason to discontinue therapy 1

Monitoring Protocol

• Baseline assessment: Measure eGFR and urine ACR before starting SGLT2 inhibitor therapy 1
• Follow-up monitoring:
  • eGFR: Every 3-6 months if <60 mL/min/1.73 m², annually if ≥60 mL/min/1.73 m² 1
  • Urine ACR: Annually, or more frequently if elevated 1
  • Increase monitoring frequency based on the risk stratification shown in guidelines (1-4 times per year) 1

Safety Considerations

• Monitor for genital mycotic infections, which are more common with SGLT2 inhibitors 1, 2
• Educate patient about symptoms of volume depletion (lightheadedness, orthostasis, weakness) 1
• Consider reducing diuretic doses if the patient is also on diuretic therapy 1
• Instruct the patient to temporarily withhold the SGLT2 inhibitor during periods of:
  • Prolonged fasting
  • Surgery
  • Critical illness
  • Reduced oral intake 1
• Monitor for diabetic ketoacidosis, which can occur even with normal blood glucose levels 1, 2

Additional Therapeutic Considerations

• Consider adding an ACE inhibitor or ARB if hypertension or albuminuria is present 1
• If additional glycemic control is needed, consider a GLP-1 receptor agonist, which also offers cardiovascular benefits 1
• For patients with albuminuria ≥300 mg/g, aim for a reduction of ≥30% in albuminuria to slow CKD progression 1
• Dietary protein intake should be maintained at 0.8 g/kg body weight per day for patients with stage G3 or higher CKD 1

When to Refer to Nephrology

• Refer to a nephrologist if:
  • eGFR <30 mL/min/1.73 m²
  • Continuously increasing urinary albumin levels
  • Continuously decreasing eGFR
  • Uncertainty about the etiology of CKD 1

Special Considerations for African American Patients

• African Americans have higher risk of CKD progression and may benefit from more intensive monitoring 1
• Ensure equitable access to SGLT2 inhibitors and other renoprotective therapies, as disparities in access have been documented 1
• Consider genetic factors that may influence drug response and kidney disease progression in African American patients 1

By following these recommendations, the patient can optimize kidney protection while safely continuing SGLT2 inhibitor therapy, which is particularly important given her family history of kidney failure and African American ethnicity.