Effect of SGLT2 Inhibitors on CKD Progression
Several large cardiovascular outcomes trials in patients with T2D and predominantly preserved kidney function showed a reduced risk of CKD progression with the SGLT2 inhibitors empagliflozin (in EMPA-REG OUTCOME) [
17], canagliflozin (in CANVAS) [
16], and dapagliflozin (in DECLARE–TIMI 58) [
18]. More recently, a marked reduction in the risk of CKD progression with SGLT2 inhibitors was confirmed with canagliflozin in patients with DKD (in CREDENCE) [
20] and with dapagliflozin in patients with DKD or nondiabetic CKD (in DAPA-CKD and DECLARE–TIMI 58) [
19,
21,
79].
In the CREDENCE study in 4401 patients with T2D and albuminuric CKD (eGFR 30 to < 90 mL/min/1.73 m
2; UACR ≥ 300 to 5000 mg/g), canagliflozin 100 mg once daily significantly reduced the risk of the primary composite endpoint (i.e., ESKD, doubling of serum creatinine, or renal or cardiovascular death) by 30% compared with placebo (
P < 0.001) [
20]. In addition, there was a significant reduction in the risk of ESKD by 32% (
P = 0.002) and of the composite endpoint of ESKD, doubling of serum creatinine, or renal death by 34% (
P < 0.001) [
20].
In the DAPA-CKD study in 4304 patients with CKD, either with (67.5%) or without (32.5%) T2D, dapagliflozin 10 mg once daily significantly reduced the risk of the primary composite endpoint (i.e., sustained 50% or more decline in eGFR, ESKD, or renal or cardiovascular death) by 39% compared with placebo (
P < 0.001) [
21]. Further, dapagliflozin significantly reduced the risk of the secondary composite endpoint of 50% or more decline in eGFR, ESKD, or renal death by 44% (
P < 0.001) and of all-cause mortality by 31% (
P = 0.004) [
21]. Importantly, DAPA-CKD was the first trial to show reduction in risk of all-cause mortality in patients with CKD, and also the first trial of an SGLT2 inhibitor to demonstrate improvement in kidney disease outcomes, being equally effective in patients with T2D and CKD and in those with nondiabetic CKD [
80].
In the DECLARE–TIMI 58 study of patients with DKD or nondiabetic CKD, the effects of dapagliflozin compared with placebo on renal outcomes were evaluated on the basis of a composite cardiorenal (sustained decline of at least 40% in eGFR > 60 mL/min/1.73 m
2, ESKD, or death from renal or cardiovascular causes) and composite renal-specific (excluding cardiovascular death) outcomes [
18,
19,
79]. The dapagliflozin group had a significantly reduced frequency of the composite cardiorenal outcome [HR 0.76 (95% CI 0.67–0.87);
P < 0.0001] and the renal-specific outcome [HR 0.53 (95% CI 0.43–0.66);
P < 0.0001] compared with the placebo group [
19]. There was a significantly lower risk of a sustained eGFR decline by at least 40% to eGFR < 60 mL/min/1.73 m
2 [HR 0.54 (95% CI 0.43–0.67);
P < 0.0001] for dapagliflozin versus placebo [
19] and fewer patients had ESKD in the dapagliflozin group than the placebo group [HF 0.41 (95% CI 0.20–0.82);
P = 0.012] [
19]. Long-term (baseline to 4 years) changes in UACR were significantly improved with dapaglifozin versus placebo [HR 1.45 (95% CI 1.35–1.56),
P < 0.0001] irrespective of UACR or eGFR at baseline [
79]. In the dapagliflozin group compared with the placebo group, there were significant reductions in the composite cardiorenal outcome across subgroups of UACR ≥ 30 mg/g (
P < 0.0125) as well as in the renal-specific outcome across all UACR categories (
P < 0.05) [
79].
Treatment of CKD with SGLT2 Inhibitors in Clinical Practice
On the basis of the findings from CREDENCE [
20], DECLARE–TIMI 58 [
18,
19], and DAPA-CKD [
21], the US Food and Drug Administration expanded approval of canagliflozin to include patients with T2D and diabetic nephropathy, with albuminuria > 300 mg/day and an eGFR ≥ 30 mL/min/1.73 m
2 [
81], and approval of dapagliflozin to include patients with CKD with an eGFR ≥ 25 mL/min/1.73 m
2 at risk of CKD progression [
18,
19,
82]. Therefore, it is important that all healthcare providers, including primary care physicians and nephrologists, are aware of the therapeutic value that SGLT2 inhibitors add to disease management in patients with CKD.
Although canagliflozin is indicated to reduce the risk of CKD progression (i.e., ESKD or doubling of serum creatinine), cardiovascular death, and hospitalization for HF (HHF) only in patients with T2D and albuminuria ≥ 300 mg/g [
81], dapagliflozin is indicated to reduce the risk of CKD progression (i.e., ESKD or sustained eGFR decline) and HHF irrespective of albuminuria in all patients with CKD (with or without T2D), as well as to reduce the risk of cardiovascular death and HHF in patients with HF with reduced ejection fraction [
82].
SGLT2 inhibitors are associated with a reduction in glomerular hyperfiltration, likely caused by an increase in preglomerular vasoconstriction and a decrease in postglomerular vascular resistance [
83]; therefore, an initial decrease in eGFR of approximately 4–5 mL/min/1.73 m
2 is expected within the first 2–3 weeks of SGLT2 inhibitor therapy. A study in patients with type 1 diabetes suggested that this decrease in eGFR is secondary to adenosine-induced preglomerular vasoconstriction [
84], whereas a more recent study in patients with T2D indicated that a decline in eGFR may additionally be caused by postglomerular vasodilation [
83]. In the latter study, the decrease in eGFR corresponded to a reduction in intraglomerular pressure of 1.4 mmHg in euglycemia and 1.9 mmHg in hyperglycemia [
83]. This reduction in intraglomerular pressure is similar to that observed with ACE inhibitor or ARB therapy [
85]. In CREDENCE and DAPA-CKD, canagliflozin or dapagliflozin was associated with an initial mean eGFR decline of 3.7 mL/min/1.73 m
2 within 3 weeks or 4.0 mL/min/1.73 m
2 within 2 weeks, respectively, after which the decline stabilized and the annual change in eGFR was less with the SGLT2 inhibitor than with placebo [
20,
21]. This initial dip in eGFR was reported to exceed 10% in one out of four patients, but is not expected to lead to discontinuation of SGLT2 inhibitor therapy, unless eGFR decreases by 30% or more [
85,
86]. An eGFR dip of greater than 10% was typically seen in patients with more depleted volume status receiving concomitant diuretics and with more advanced CKD stages, but importantly this did not affect kidney or cardiovascular outcomes [
86].
An important consideration for SGLT2 inhibitors in patients with CKD is the potential for SGLT2 inhibitor-related adverse events. There is an increased risk of non-serious adverse events with this class, including urinary tract infections and genital mycotic infections, compared with placebo [
81,
82]; however, the risk of serious adverse events is low.
The risk of diabetic ketoacidosis (DKA), frequently presenting with euglycemia, may be increased with SGLT2 inhibitors, particularly in patients with restricted carbohydrate intake (e.g., ketogenic diet) [
87], insulin deficiency, or history of alcohol abuse [
81,
82]. In CREDENCE, the rate of DKA was higher with canagliflozin than with placebo (2.2 vs. 0.2 per 1000 patient-years) [
20], but in DAPA-CKD, there were no cases of DKA reported with dapagliflozin (vs. two with placebo) [
21].
Although there have been postmarketing reports of AKI related to volume depletion with canagliflozin and dapagliflozin in patients with T2D [
81,
82], the risk of AKI with SGLT2 inhibitors appears to be low. In DAPA-CKD, the cumulative incidence of AKI (32 months of follow-up) was lower with dapagliflozin than with placebo [2.9% vs. 4.2%; HR 0.68 (95% CI 0.49–0.94)] [
67,
88]. In CREDENCE, the incidence of AKI was similar in the canagliflozin and placebo groups [16.9 vs. 20.0 events/1000 patient-years; HR 0.85 (95% CI 0.64–1.13)] [
20]. In light of these data, the US prescribing information for canagliflozin and dapagliflozin no longer includes a warning regarding the risk of AKI; however, a new warning is included to monitor for signs and symptoms of volume depletion for the class [
81,
82,
89]. Furthermore, a recent meta-analysis of 18 trials (
N = 156,690) showed that the risk of AKI with SGLT2 inhibitors was 24% lower versus placebo, 32% lower versus DPP4 inhibitors, and 21% lower versus GLP1-RAs [
90].
An initial increase in diuresis at the start of SGLT2 inhibitor therapy should be anticipated to avoid volume depletion and low SBP, especially in patients with eGFR < 60 mL/min/1.73 m
2, older patients, or those on loop diuretics [
81,
82]. SGLT2 inhibitors cause glucosuria-induced osmotic diuresis and natriuresis, which can lead to a total fluid loss of about 1–2 kg in the first 1–2 weeks of treatment that subsequently stabilizes [
91]. Volume depletion should be corrected before initiation of an SGLT2 inhibitor and a reduction in diuretic therapy considered. This increase in diuresis is not associated with any notable electrolyte disorders [
92]. In CREDENCE, the incidence of volume depletion was higher with canagliflozin than with placebo (28.4 vs. 23.5 events/1000 patient-years [
93]. Similarly, in DAPA-CKD, volume depletion was reported in a higher proportion of patients in the dapagliflozin group than in the placebo group (5.9% vs. 4.2%) [
21]. Canagliflozin lowered SBP by approximately 3.5 mmHg versus placebo in the CREDENCE study, irrespective of concomitant antihypertensive therapy [
94]. The mechanism for this SBP reduction is unclear but appears to be related to vasodilation without an increase in pulse rate [
91] and reduction of sympathetic tone [
95].
Canagliflozin has been associated with an increased risk of lower limb amputations and fractures in patients with T2D [
16,
96]; however, the rates of lower limb amputation and fractures with canagliflozin were similar to those observed with placebo in patients with CKD in CREDENCE [
20]. Similarly, dapagliflozin was not associated with an increased risk of amputation or fracture compared with placebo in DAPA-CKD [
21]. This suggests that the risks of lower limb amputation and fractures are not increased with canagliflozin or dapagliflozin in patients with CKD.
When used as monotherapy in patients with T2D, the risk of hypoglycemia with SGLT2 inhibitors is low because of their insulin-independent mechanism of action but may be increased when used in combination with insulin or an insulin secretagogue (e.g., sulfonylurea) [
81,
82]. Similar rates of hypoglycemia (severity not specified) were observed with canagliflozin and placebo (10.2% vs. 10.9%) in patients with CKD in CREDENCE [
20], and the incidence of major hypoglycemia with dapagliflozin was lower than that with placebo (0.7% vs. 1.3%) in DAPA-CKD [
21]. There were no reports of major hypoglycemia or DKA with dapagliflozin in patients without T2D in DAPA-CKD [
21].
The risk of urinary tract infections and genital mycotic infections is increased with SGLT2 inhibitors because of the increased urinary excretion of glucose, and genital mycotic infection is common in women with a past history [
97]. In CREDENCE, the rate of urinary tract infections was similar with canagliflozin versus placebo, but the rate of genital mycotic infections was higher with canagliflozin in both men (8.4 vs. 0.9 per 1000 patient-years) and women (12.6 vs. 6.1 per 1000 patient-years) [
20]. In DAPA-CKD, serious urinary tract infections were rare, with an incidence of 0.9% with dapagliflozin versus 0.7% with placebo, and no serious genital mycotic infections were reported [
21].
The benefits of SGLT2 inhibitors in slowing CKD progression versus the risks for treatment-related adverse effects necessitate individualization of treatment. When initiating SGLT2 inhibitors for CKD, physicians should assess the benefits of reducing CKD progression, including delay to ESKD and reduction in all-cause mortality with the potential risk of an initial increase in diuresis, DKA, and urinary tract and genital mycotic infections as well as take into consideration underlying comorbidities and concomitant medications.
Other Potential Therapeutic Agents in CKD
Other drug classes have shown potential for improved outcomes in patients with CKD, including MRAs and GLP1-RAs.
The MRA finerenone was recently approved in patients with CKD and T2D to reduce the risk of CKD progression, cardiovascular death, nonfatal MI, and HHF [
98]. This approval was based on the findings of the FIDELIO-DKD study, in which the efficacy and safety of finerenone was evaluated in 5674 patients with T2D and either moderately albuminuric CKD (UACR 30 to < 300 mg/g and eGFR 25 to < 60 mL/min/1.73 m
2) and diabetic retinopathy or severely albuminuric CKD (UACR ≥ 300 to 5000 mg/g and eGFR 25 to < 75 mL/min/1.73 m
2) [
22]. In FIDELIO-DKD, finerenone was associated with a significantly reduced risk of CKD progression (i.e., kidney failure, sustained at least 40% decrease in eGFR, or renal death) compared with placebo, as well as a 31% greater reduction in UACR from baseline after 4 months [
22]. However, the risk of hyperkalemia with finerenone increases with decreasing kidney function, particularly in patients with higher potassium levels prior to initiating therapy [
98]. In FIDELIO-DKD, the incidence of hyperkalemia was higher with finerenone than with placebo (15.8% vs. 7.8%) and more patients discontinued treatment because of hyperkalemia with finerenone versus placebo (2.3% vs. 0.9%) [
22].
In studies of patients with T2D and predominantly preserved renal function (only 22–23% had an eGFR < 60 mL/min/1.73 m
2), GLP1-RA therapy was associated with significant reductions in UACR or the risk of new-onset macroalbuminuria, but there was no significant reduction in the risk of CKD progression or ESKD compared with placebo [
99‐
101]. In comparison, in the AWARD-7 study in patients with T2D and moderate-to-severe CKD (eGFR 15 to > 60 mL/min/1.73 m
2), dulaglutide was associated with a significantly smaller decline in eGFR and greater reductions in UACR compared with insulin glargine [
68]. The potential benefits of GLP1-RAs in patients with CKD are being further investigated in the FLOW study, a designated renal outcome study of semaglutide in patients with T2D and CKD that is currently in progress (NCT03819153; expected completion August 2024).