SGLT2 Inhibitors Should Be Discontinued When Dialysis Is Initiated
SGLT2 inhibitors are not recommended for patients on renal dialysis, as they lack efficacy in this population and have not been adequately studied for safety or benefit once kidney replacement therapy begins. 1
Guideline-Based Recommendations
When to Stop SGLT2 Inhibitors
The KDIGO 2022 guidelines explicitly state that SGLT2 inhibitors should be discontinued once kidney replacement therapy is initiated. 1
While SGLT2 inhibitors can be continued even if eGFR falls below 20 mL/min/1.73 m² in patients already taking them, this continuation is only reasonable "unless kidney replacement therapy is initiated." 1
Why SGLT2 Inhibitors Don't Work on Dialysis
SGLT2 inhibitors work by blocking glucose reabsorption in the proximal tubule of functioning kidneys—a mechanism that becomes irrelevant once patients are on dialysis. 1
The glucose-lowering efficacy of SGLT2 inhibitors diminishes progressively as eGFR declines, with minimal glycemic effects below eGFR 20 mL/min/1.73 m². 2
In dialysis patients, there is insufficient residual kidney function for SGLT2 inhibitors to exert their primary mechanism of action. 3
Recent FDA Labeling Changes Create Confusion
Dapagliflozin Labeling Update
The FDA removed the requirement to discontinue dapagliflozin when dialysis is initiated after reviewing safety data from patients who started dialysis during the DAPA-CKD trial. 1
However, this labeling change was based solely on the absence of safety signals—not on evidence of efficacy or benefit in dialysis patients. 1
The KDOQI Work Group explicitly states there is not enough evidence to suggest SGLT2 inhibitors are effective in patients receiving kidney replacement therapy. 1
Other SGLT2 Inhibitors
Empagliflozin is contraindicated in patients with eGFR <30 mL/min/1.73 m² and should not be used when eGFR is persistently <45 mL/min/1.73 m². 4
Canagliflozin labeling does not support use in dialysis patients. 5
Limited Research in Dialysis Populations
Incremental Hemodialysis Study
One small retrospective study (n=7) examined SGLT2 inhibitors in patients on incremental hemodialysis (1-2 sessions per week) who still had measurable residual kidney function. 6
These patients showed preservation of residual kidney urea clearance over 12 months, but this represents a fundamentally different population than conventional dialysis patients with minimal or no residual function. 6
This study does not support SGLT2 inhibitor use in standard dialysis patients without significant residual kidney function. 6
Ongoing Trials
- Clinical trials are currently exploring potential benefits of SGLT2 inhibitors in dialysis patients, but results are not yet available. 1
Clinical Algorithm for SGLT2 Inhibitor Use by Kidney Function
eGFR ≥20 mL/min/1.73 m²
- Initiate and continue SGLT2 inhibitors for kidney and cardiovascular protection. 1
- Continue even if eGFR declines below 20 mL/min/1.73 m² as long as the patient remains off dialysis. 1
eGFR <20 mL/min/1.73 m² (Pre-Dialysis)
- Continue SGLT2 inhibitors if already taking and tolerating well. 1
- Do not initiate new SGLT2 inhibitor therapy for heart failure indication if eGFR <20 mL/min/1.73 m². 2
Dialysis Initiation
- Discontinue SGLT2 inhibitors when dialysis is started. 1
- The mechanism of action requires functioning proximal tubules, which are bypassed by dialysis. 1
Alternative Glucose-Lowering Options for Dialysis Patients
GLP-1 Receptor Agonists
GLP-1 receptor agonists retain glucose-lowering efficacy in dialysis patients and are the preferred alternative. 1
These agents have been studied with eGFR as low as 15 mL/min/1.73 m² and maintain potency across the full range of kidney function. 1
DPP-4 Inhibitors
Selected DPP-4 inhibitors (such as sitagliptin with dose adjustment) can be safely used in dialysis patients. 1
These provide a safe and effective option when GLP-1 receptor agonists are not tolerated or available. 1
Insulin
- Insulin remains the cornerstone of glycemic management in dialysis patients, though doses often need reduction due to decreased insulin clearance. 1
Critical Safety Considerations
Volume depletion risk from SGLT2 inhibitors becomes irrelevant in dialysis patients who have volume status managed by ultrafiltration. 1
The risk of genital mycotic infections and urinary tract infections would theoretically persist even without drug efficacy. 4, 5
Continuing SGLT2 inhibitors in dialysis patients exposes them to potential adverse effects without providing therapeutic benefit. 1