Are Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors still indicated for heart failure in patients with anuria (absence of urine production)?

From the Guidelines

SGLT2 inhibitors are still indicated for heart failure in patients with anuria, as they provide cardiovascular benefits through mechanisms independent of their diuretic effects, and the most recent evidence suggests their use can be beneficial in patients with severe renal impairment, including those on dialysis 1.

Key Considerations

• The 2025 KDOQI US commentary on the KDIGO 2024 clinical practice guideline for the evaluation and management of CKD supports the use of SGLT2 inhibitors as a first-line agent for kidney and heart protection in patients with eGFR ≥ 20 mL/min per 1.73 m² and UACR ≥ 200 mg/g 1.
• The FDA has removed the statement that dapagliflozin should be discontinued when dialysis is initiated, suggesting that SGLT2 inhibitors may be safe to use in patients receiving dialysis 1.
• Ongoing trials are exploring the potential benefits of SGLT2 inhibitors in dialysis and transplant patients, which may provide further guidance on their use in these populations.

Clinical Implications

• For patients with anuria, standard heart failure dosing of SGLT2 inhibitors applies: empagliflozin 10mg daily, dapagliflozin 10mg daily, or canagliflozin 100mg daily.
• The decision to use SGLT2 inhibitors in anuric patients should be individualized based on the overall clinical picture and potential benefits for heart failure management.
• Clinicians should consider the potential cardiovascular benefits of SGLT2 inhibitors, including improved cardiac energetics, reduced cardiac fibrosis, decreased cardiac preload and afterload, and anti-inflammatory effects, when making treatment decisions for patients with heart failure and anuria.

Important Safety Information

• SGLT2 inhibitors may increase the risk of mycotic genital infections, ketoacidosis, and acute kidney injury, and patients should be monitored for these potential adverse effects 1.
• The use of SGLT2 inhibitors in patients with anuria requires careful consideration of the potential benefits and risks, and clinicians should be prepared to adjust treatment plans as needed to minimize adverse effects.

From the Research

SGLT2 Inhibitors in Heart Failure

• SGLT2 inhibitors have been shown to reduce the risk of heart failure hospitalizations and cardiovascular mortality in patients with heart failure, including those with reduced ejection fraction 2, 3, 4.
• The benefits of SGLT2 inhibitors in heart failure are evident across various subgroups, including patients with different ages, sexes, races, and ejection fractions 2.
• However, the use of SGLT2 inhibitors in patients with anuria is not explicitly addressed in the provided studies.

Considerations for SGLT2 Inhibitor Use

• SGLT2 inhibitors can be initiated early in the treatment of heart failure to achieve rapid clinical benefits 5.
• A clinical practice algorithm can assist in identifying patients who may be eligible for SGLT2 inhibitor treatment and in monitoring their response to therapy 3.
• The evidence for the use of SGLT2 inhibitors in heart failure is based on studies that excluded patients with significant renal impairment, including anuria 2, 3, 4.

Renal Impairment and SGLT2 Inhibitors

• The provided studies do not specifically address the use of SGLT2 inhibitors in patients with anuria, which is a significant renal impairment.
• However, it is known that SGLT2 inhibitors can have renal effects, including increases in serum creatinine and decreases in eGFR 2, 3.
• Further research is needed to determine the safety and efficacy of SGLT2 inhibitors in patients with significant renal impairment, including anuria.