Advancing American Kidney Health and the Role of Sodium-Glucose Cotransporter-2 Inhibitors: A Missed Opportunity

Considerations and possibilities for sodium-glucose cotransporter 2 inhibitors in pediatric CKD

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) were originally developed as glucose-lowering agents. These medications function by inhibiting glucose and sodium reabsorption in the S1 segment of the proximal tubule. Early clinical trials in adults with type 2 diabetes mellitus (T2DM) suggested a significant improvement in kidney and cardiovascular outcomes with SGLT2i therapy. Since then, SGLT2is have become a mainstay treatment for adult patients with CKD. A growing body of research has explored deploying these medications in new clinical contexts and investigated the mechanisms underlying their physiologic effects. However, patients under the age of 18 years have been largely excluded from all major trials of SGLT2i. This review aims to summarize the available clinical evidence, physiology, and mechanisms relating to SGLT2is to inform discussions about their implementation in pediatrics.

Prescribing Patterns of Sodium-Glucose Cotransporter-2 Inhibitors in Patients with CKD: A Cross-Sectional Registry Analysis

Background

Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) reduce kidney disease progression and mortality in patients with chronic kidney disease (CKD), regardless of diabetes status. However, the prescribing patterns of these novel therapeutics in the CKD population in real-world settings remain largely unknown.

Methods

This cross-sectional study included adults with stages 3-5 CKD included in the Mass General Brigham (MGB) CKD registry in March 2021. We described the adoption of SGLT-2i therapy and evaluated factors associated with SGLT-2i prescription using multivariable logistic regression models in the CKD population, with and without diabetes.

Results

A total of 72,240 patients with CKD met the inclusion criteria, 31,688 (44%) of whom were men and 61,265 (85%) White. A total of 22,653 (31%) patients were in the diabetic cohort, and 49,587 (69%) were in the nondiabetic cohort. SGLT-2i prescription was 6% in the diabetic cohort and 0.3% in the nondiabetic cohort. In multivariable analyses, younger Black men with a history of heart failure, use of cardiovascular medications, and at least one cardiologist visit in the previous year were associated with higher odds of SGLT-2i prescription in both diabetic and nondiabetic cohorts. Among patients with diabetes, advanced CKD stages were associated with lower odds of SGLT-2i prescription, whereas urine dipstick test and at least one subspecialist visit in the previous year were associated with higher odds of SGLT-2i prescription. In the nondiabetic cohort, CKD stage, urine dipstick test, and at least one nephrologist visit in the previous year were not significantly associated with SGLT-2i prescription.

Conclusions

In this registry study, prescription of SGLT-2i was low in the CKD population, particularly among patients without diabetes.