Should Dapagliflozin Be Added for Renal Protection?
Yes, dapagliflozin 10 mg once daily should be initiated for renal and cardiovascular protection in this elderly male patient with GFR 50 and hypertension, as it reduces the risk of kidney disease progression by 44% and cardiovascular death or heart failure hospitalization by 29%, with benefits independent of diabetes status. 1, 2
Evidence Supporting Initiation at GFR 50
The 2019 ESC guidelines recommend treatment with an SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) for patients with eGFR 30 to <90 mL/min/1.73 m², as it is associated with a lower risk of renal endpoints 1
Dapagliflozin can be initiated at 10 mg daily when eGFR ≥25 mL/min/1.73 m² for cardiovascular and renal protection, making this patient with GFR 50 an ideal candidate 3, 4
The DAPA-CKD trial demonstrated that dapagliflozin 10 mg daily reduced the primary composite outcome (sustained eGFR decline ≥50%, end-stage kidney disease, or renal/cardiovascular death) by 39% (HR 0.61,95% CI 0.51-0.72) in patients with eGFR 25-75 mL/min/1.73 m² 2
Renal Protection Benefits
The kidney-specific composite outcome (sustained eGFR decline ≥50%, end-stage kidney disease, or renal death) was reduced by 44% (HR 0.56,95% CI 0.45-0.68) 2
Dapagliflozin slows the rate of long-term eGFR decline, with patients experiencing an initial eGFR dip of 3-5 mL/min/1.73 m² in the first 1-4 weeks, followed by stabilization and slower subsequent decline compared to placebo 3, 5
Patients who experienced an acute eGFR reduction >10% at 2 weeks actually had better long-term renal outcomes with slower eGFR decline (-1.58 vs -2.44 ml/min/1.73 m²/year) compared to those without an initial dip 3, 5
Cardiovascular Benefits
Dapagliflozin reduced cardiovascular death or hospitalization for heart failure by 29% (HR 0.71,95% CI 0.55-0.92) 2
All-cause mortality was reduced by 31% (HR 0.69,95% CI 0.53-0.88) 2
These cardiovascular benefits occur independently of diabetes status, with similar efficacy in patients with type 2 diabetes (HR 0.64) and those without diabetes (HR 0.50) 6
Dosing and Administration
The recommended dose is 10 mg orally once daily for cardiovascular and renal protection, regardless of diabetes status 3, 4
No dose adjustment or up-titration is required, as dapagliflozin does not affect blood pressure, heart rate, or potassium levels significantly 1
For this patient with GFR 50, the standard 10 mg daily dose is appropriate and should not be reduced 3
Safety Considerations in Elderly Patients
Before initiating dapagliflozin, assess volume status and correct volume depletion if present, as elderly patients and those on diuretics are at increased risk for volume depletion 4
If the patient is on concurrent diuretics, consider reducing diuretic doses to prevent excessive volume depletion 3
Monitor eGFR and creatinine within 1-2 weeks after initiation to assess the expected transient decrease 3
Educate the patient to withhold dapagliflozin during acute illness with reduced oral intake, fever, vomiting, or diarrhea 3
Common Pitfalls to Avoid
Do not discontinue dapagliflozin solely because eGFR falls below 45 mL/min/1.73 m², as cardiovascular and renal protective benefits persist even when glycemic efficacy is lost 3
Do not withhold initiation due to concerns about the initial eGFR dip, as this transient reduction (3-5 mL/min/1.73 m²) is expected and reversible, followed by long-term renal protection 3, 5
Do not wait for albuminuria testing before initiating, as the 2019 ESC guidelines recommend SGLT2 inhibitors for patients with eGFR 30-90 mL/min/1.73 m² regardless of albuminuria status 1
Monitoring Plan
Check eGFR within 1-2 weeks after initiation, then at least every 3-6 months 3
Monitor for genital mycotic infections (occur in approximately 6% of patients) and urinary tract infections 3, 4
Assess volume status closely in the first few weeks, particularly if the patient is on concurrent diuretics 4
Continue dapagliflozin even if eGFR falls below 25 mL/min/1.73 m² during treatment, until dialysis is required 3, 4