Safety of SGLT2 inhibitors in patients with different glomerular diseases treated with immunosuppressive therapies

Dual-faced guardians: SGLT2 inhibitors' kidney protection and health challenges: a position statement by Kasralainy nephrology group (KANG)

BACKGROUND

SGLT2 inhibitors represent a revolutionary drug class that delivers benefits exceeding those of diabetes management alone. Initially approved for type 2 diabetes management, research continually demonstrates their protective effects on kidney function across several nephrological conditions, including acute kidney injury (AKI), chronic kidney disease (CKD), dialysis-dependent kidney failure, anemia, metabolic bone disease, polycystic kidney disease (PKD), glomerulonephritis, and kidney transplantation.

PURPOSE

This study aims to identify how SGLT2 inhibitors modify nephrological care by investigating their mechanisms of action, therapeutic outcomes, and potential applications in multiple kidney diseases. It summarizes clinical trial data alongside mechanistic insights to provide a comprehensive assessment of therapeutic outcomes beyond diabetes mellitus.

FINDINGS

Numerous clinical studies have demonstrated that SGLT2 inhibitors reduce kidney disease progression in patients with or without diabetes. These findings indicate that SGLT2 inhibitors provide kidney protection by enhancing tubuloglomerular feedback, improving renal blood flow, and reducing inflammation and ischemic tissue damage. They also provide cardiovascular benefits to dialysis patients while maintaining effective blood flow during dialysis. SGLT2 inhibitors should not be used in autosomal dominant polycystic kidney disease (ADPKD) outside clinical trials. The potential impact of SGLT2 inhibitors on bone mineral health, particularly regarding bone mineral density (BMD) reduction and fracture risk, requires careful consideration, especially in patients with pre-existing bone health concerns. Kidney transplant recipients benefit from SGLT2 inhibitors' protective effects on kidney health and assistance with diabetes management; however, further research is needed on drug compatibility with immunosuppressants and infection prevention.

SGLT2 Inhibitors in Glomerulonephritis: Beyond Nephroprotection?

Sodium-glucose cotransporter 2 (SGLT2) inhibitors, initially developed for glycaemic control in type 2 diabetes, have demonstrated substantial renal and cardiovascular protective effects across various chronic kidney diseases (CKD), including glomerulonephritis. Beyond their established haemodynamic and metabolic benefits, recent evidence points to additional mechanisms of action potentially relevant to immune-mediated kidney diseases, such as the modulation of inflammation, immunometabolism, and oxidative stress. Randomised clinical trials (DAPA-CKD and EMPA-KIDNEY) and real-world observational studies consistently show that SGLT2 inhibitors reduce proteinuria and slow estimated glomerular filtration rate (eGFR) decline in patients with glomerulonephritis, including IgA nephropathy and focal segmental glomerulosclerosis. These benefits may extend to patients with stable immunosuppression. Further data are needed in this subgroup. Importantly, SGLT2 inhibitors display a favourable safety profile, even among those with immunosuppressed status. Again, further evidence is awaited in this respect. Despite these promising findings, unanswered questions remain regarding their efficacy in nephrotic syndrome, early-stage disease, and in comparison or combination with other supportive therapies. Overall, the evolving evidence supports the inclusion of SGLT2 inhibitors as a key component of supportive therapy in glomerulonephritis, with potential benefits extending beyond proteinuria reduction.

The Role of Sodium-Glucose Co-Transporter-2 (SGLT-2) Inhibitors in Treating Lupus Nephritis: A Systematic Review

Systemic lupus erythematosus (SLE) is a prevalent autoimmune condition worldwide resulting from the loss of tolerance against self-antigens. The constitutional symptoms of SLE are well-known, including fatigue, fever, myalgia, weight loss, arthralgia, arthritis, malar rash, and photosensitivity. These symptoms often overshadow the impacts SLE can have on all body systems, with the renal system frequently impacted. Inflammation of the nephrons can progress to end-stage renal disease and renal failure if not treated effectively. Currently, the medications that are being utilized for the treatment of lupus nephritis (LN), include azathioprine, hydroxychloroquine, cyclophosphamide, belimumab, voclosporin, tacrolimus, mycophenylate, and rituximab. However, the majority of these medications are used off-label, and many come with severe side effects. With the additional benefits of anti-diabetic medications being examined outside of their original purpose, sodium-glucose co-transporter-2 (SGLT-2) inhibitors have begun to be investigated for their role in LN. To determine the impact of SGLT-2 inhibitors on LN risk and progression, a preliminary systematic review was conducted. A total of 248 articles were analyzed, with six being selected. SGLT-2 inhibitors were found to improve glomerular filtration rate (GFR), reduce proteinuria and albuminuria, and reduce the inflammatory cascade. The exploration of SGLT-2 inhibitors as a therapeutic strategy for LN represents a promising and innovative approach to managing this complex condition. SGLT-2 inhibitors show potential benefits beyond glycemic control. However, due to the novelty of this treatment and the limited studies completed, further testing is required to analyze its true effectiveness in LN.

Progress of SGLT2 inhibitors in the treatment of common immune-related nephropathies

The immune system can lead to a variety of renal diseases through direct or indirect mechanisms. In immune-mediated nephropathy, though standardized treatment, there are still a small number of patients with further decline in renal function, which may even progress to renal failure; sodium-glucose cotransporter protein 2 (SLC5A2,SGLT2) inhibitors not only can significantly reduce blood glucose, but also have an additional protective effect on the kidneys and the heart; this review concludes the potential mechanism of the renal protective effect of SGLT2i and the new advances in the recent years in common immune-mediated nephropathies, which can provide new theoretical references to optimize the therapeutic strategy of common immune-mediated nephropathies.

Clinical value of adding Dapagliflozin in patients with nephrotic syndrome

BACKGROUND

Sodium-glucose cotransporter 2 (SGLT2) inhibitors in nephrotic patients on immunosuppression are underexplored. We evaluated dapagliflozin's impact in non-diabetic primary nephrotic syndrome.

METHODS

Randomized controlled clinical trial was conducted on 60 non-diabetic primary nephrotic syndrome patients, equally assigned to dapagliflozin and control groups. All patients received the standard of care medication and the Dapagliflozin group received 10 mg dapagliflozin in addition. Demographic data, nephrotic syndrome etiology, proteinuria levels, eGFR, and immunosuppression doses, were well-matched. After 6 months of follow up primary outcomes included changes in and eGFR.

RESULTS

Both groups exhibited significant reductions in proteinuria after 6 months, with the dapagliflozin group achieving a mean UPCR reduction of  - 94.7%, and the control group  - 86.7% (p < 0.001). However, the comparative change in proteinuria between both groups did not reach statistical significance (p = 0.158). Dapagliflozin initially led to a transient eGFR decline. Dapagliflozin also resulted in a significant mean body weight reduction (p < 0.001) and notable improvements in triglyceride levels compared to the control group (p = 0.045).

CONCLUSION

In primary nephrotic syndrome patients, adjunct dapagliflozin may enhance the standard of care. While notable, the reduction in proteinuria was comparable to that of the control group by the study's end. Furthermore, after 6 months, eGFR remained stable in both groups. However, significant weight loss and serum triglyceride reduction were particularly pronounced in the dapagliflozin group. Further long-term investigations are necessary to address potential immunosuppression-related confounding effects in patients with primary glomerular disease.

Sodium glucose co-transporter 2 inhibitors in the treatment of glomerular diseases: a CKJ controversy

Integrating sodium-glucose co-transporter 2 inhibitors (SGLT2i) into the treatment for chronic kidney disease (CKD) has marked a significant therapeutic advance in nephrology. Clinical trials such as DAPA-CKD and EMPA-KIDNEY have demonstrated the beneficial effects of SGLT2i in slowing CKD progression and reducing proteinuria. However, the applicability of these results to patients with glomerulonephritis is still unresolved due to various limitations. This manuscript combines the evidence supporting the use of SGLT2i in glomerular diseases, highlights the limitations and strikes a conclusive balance on their role in clinical practice.