Discontinue SGLT2 Inhibitors in Pauci-Immune Glomerulonephritis
You should discontinue SGLT2 inhibitors during active pauci-immune glomerulonephritis, as this represents an acute inflammatory kidney disease requiring immunosuppression, and SGLT2 inhibitors should be withheld during acute kidney injury or critical medical illness. 1
Rationale for Discontinuation
Pauci-immune glomerulonephritis is an acute, severe kidney disease that requires immediate immunosuppressive therapy and represents a critical medical illness where SGLT2 inhibitors should be held. 1 The KDIGO guidelines explicitly recommend withholding SGLT2 inhibitors during times of critical medical illness when patients may be at greater risk for ketosis 1. Active glomerulonephritis with rapidly declining kidney function qualifies as such a condition.
Key Safety Concerns During Active Disease
Volume depletion risk is substantially elevated during acute glomerulonephritis when patients may have reduced oral intake, require high-dose corticosteroids (which affect fluid balance), and potentially need concurrent diuretic therapy 1
Euglycemic diabetic ketoacidosis risk increases during critical illness, particularly when combined with reduced food intake and the metabolic stress of acute kidney inflammation 1
Acute kidney injury is a contraindication for continuing SGLT2 inhibitors, as the hemodynamic effects (reduced intraglomerular pressure) may worsen acute kidney function decline in the setting of active inflammation 1
When to Consider Restarting
Once the glomerulonephritis is in remission, kidney function has stabilized, and eGFR is ≥25 mL/min/1.73 m², you can restart the SGLT2 inhibitor for cardiovascular and renal protection. 1
Criteria for Safe Reinitiation
Stable kidney function for at least 3 months with no ongoing acute inflammatory activity 1
eGFR ≥25 mL/min/1.73 m² at minimum, though ≥30 mL/min/1.73 m² is preferable for diabetic patients 1
Patient is no longer on high-dose immunosuppression and has resumed normal oral intake 1
Volume status is stable without requirement for aggressive diuretic therapy 1
Monitoring After Reinitiation
Check eGFR within 1-2 weeks after restarting, as an initial reversible decline of 3-5 mL/min/1.73 m² is expected and does not require discontinuation 2, 3
Assess volume status carefully, particularly if the patient remains on any dose of corticosteroids or diuretics 1
Continue monitoring eGFR every 3-6 months if eGFR is 30-59 mL/min/1.73 m², or at least annually if ≥60 mL/min/1.73 m² 1, 2
Long-Term Management Considerations
For diabetic patients with a history of pauci-immune glomerulonephritis who have coronary artery disease or cardiomyopathy, SGLT2 inhibitors provide substantial mortality benefit once kidney function stabilizes. 1, 4 The cardiovascular benefits (35% reduction in heart failure hospitalization, 26% reduction in cardiovascular death or worsening heart failure) are maintained even at lower eGFR levels 1, 5.
Common Pitfall to Avoid
Do not restart SGLT2 inhibitors too early while kidney function is still fluctuating or while the patient remains on high-dose immunosuppression. 1 Wait for clear evidence of disease remission and stable kidney function for at least 3 months before considering reinitiation 1.