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Review
. 2023 Oct 25;24(1):310.
doi: 10.1186/s12882-023-03339-3.

UK Kidney Association Clinical Practice Guideline: Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease 2023 UPDATE

Alistair J Roddick  1   2 , Alexa Wonnacott  3 , David Webb  4 , Angela Watt  5 , Michael A Watson  5 , Natalie Staplin  1 , Alex Riding  6 , Eirini Lioudaki  7 , Apexa Kuverji  8 , Mohsen El Kossi  9 , Patrick Holmes  10 , Matt Holloway  11 , Donald Fraser  3 , Chris Carvalho  12   13 , James O Burton  14 , Sunil Bhandari  15 , William G Herrington #  1   2 , Andrew H Frankel #  16
Affiliations
Review

UK Kidney Association Clinical Practice Guideline: Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease 2023 UPDATE

Alistair J Roddick et al. BMC Nephrol. .

Abstract

Large placebo-controlled trials have demonstrated kidney and cardiovascular clinical benefits of SGLT-2 inhibitors. Data from the EMPA-KIDNEY and DELIVER trials and associated meta-analyses triggered an update to the UK Kidney Association Clinical Practice Guideline on Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibition in Adults with Kidney Disease. We provide a summary of the full guideline and highlight the rationale for recent updates. The use of SGLT-2 inhibitors in people with specific medical conditions, including type 1 diabetes, kidney transplants, and people admitted to hospital with heart failure is also considered, along with Recommendations for future research and Recommendations for implementation. A full "lay" summary of the guidelines is provided as an appendix to ensure that these guidelines are accessible and understandable to people who are not medical professionals.

Keywords: Acute kidney injury; Chronic kidney disease; Gliflozin; Guideline.

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Conflict of interest statement

SB reports honoraria for lectures, presentations and speaker bureaus from Astra Zeneca. JOB reports a leadership position as chair of the UK Kidney Association Clinical Practice Guidelines Committee and reports honoraria for speaker bureaus from AstraZeneca, Boehringer-Ingelheim and NAPP. CC reports support from North East London Integrated Care Board, Clinical Effectiveness Group, Queen Mary University of London, and National Institute of Health Research, and reports a grant or contract from the NIHR School of Primary Care Research. MEK reports participation on advisory boards for GlaxoSmithKline and Astella. AHF reports an institutional grant from Boehringer-Ingelheim for participation in the EMPA-KIDNEY study, honoraria or personal fees from Boehringer-Ingelheim and AstraZeneca, support for attending meetings from AstraZeneca, and participation in advisory boards for Boehringer-Ingelheim and AstraZeneca. DF reports unpaid leadership roles with the American Society of Nephrology Education Committee, EuroPD management board, and the International Society of Peritoneal Dialysis Programme Committee. MH reports honoraria from AstraZeneca and UK Renal Pharmacy Group. PH reports a personal grant from Roche Diagnostics, honoraria or personal fees from AstraZeneca, NovoNordisk and Boehringer-Ingelheim, and participation in data safety monitoring board or advisory boards for Abbott, AstraZeneca, and Bayer. AJR, WGH and NS report institutional grant funding from Boehringer-Ingelheim and Eli Lilly. NS additionally reports institutional grant funding from NovoNordisk. WGH additionally reports funding from the UK Medical Research Council–Kidney Research UK Professor David Kerr Clinician Scientist Award. AWa reports honoraria and support for travel expenses from GlaxoSmithKline. DW reports honoraria from ABCD and Sanofi Aventis and reports participation in a data safety monitoring board or advisory board for the BARI 2 study. AWo reports honoraria from Bayer and AstraZeneca and participant in advisory board for Bayer. AK, EL, MAW, and AR have no competing interests to declare.

Figures

Fig. 1
Fig. 1
Absolute benefit and risks of SGLT-2 inhibition for people with CKD with and without diabetes, estimated from 13 large randomised clinical trials of SGLT-2 inhibition (adapted from [4]). CKD – chronic kidney disease. eGFR – estimated glomerular filtration rate. SE – standard error. SGLT-2i – sodium-glucose co-transporter 2 inhibitor. Figure licensed under Creative Commons CC-BY license
Fig. 2
Fig. 2
Effects of SGLT-2 inhibition on kidney disease progression by primary kidney diagnosis (adapted from [4]). *RR in the diabetic kidney disease or nephropathy subgroup excluding SCORED (which did not formally assess primary kidney disease) is 0.59 (95% CI 0.52–0.68). Figure licensed under Creative Commons CC-BY license
Fig. 3
Fig. 3
Effects of empagliflozin versus placebo on the rate of eGFR decline in EMPA-KIDNEY, by key subgroups (adapted from [3]). Mean annual rate of change in eGFR (mL/min/1.73m2/year) from baseline to final follow-up visit (total slope) and from two months to final follow-up visit (chronic slope). The long-term (i.e. chronic slope) is emphasised as other data has demonstrated that the acute negative eGFR dip on initiation of SGLT2 inhibitors reverses on cessation, which is not accounted for in total slope analyses. This is particularly relevant when studying people whose kidney disease progresses slowly over short periods of time (e.g. 2 years), during which time progression is likely to be less than the acute negative eGFR dip (as was the case in the uACR < 30 mg/g group). Figure licensed under CC BY-ND 4.0 International license
Fig. 4
Fig. 4
Effects of empagliflozin versus placebo on the primary outcome of EMPA-KIDNEY, by baseline eGFR (post-hoc analysis). Post-hoc analysis of unpublished data from EMPA-KIDNEY
Fig. 5
Fig. 5
Effects of SGLT-2 inhibitors on kidney disease progression by population (adapted from [4]). Kidney disease progression was defined as a sustained ≥ 50% decline in eGFR from randomisation, kidney failure, or death from kidney failure. Data not available for SOLOIST-WHF. Figure licensed under Creative Commons CC-BY license
See this image and copyright information in PMC

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