Benefits of SGLT2 inhibitors in patients with diabetes and advanced chronic kidney disease – where have we gone so far?

SGLT2 inhibitors have transformed the care of patients with diabetes, chronic kidney disease (CKD), and cardiovascular disease. Nevertheless, the efficacy of SGLT2 inhibitors as well as potential associated risks remains to be further clarified in the setting of advanced diabetic kidney disease. Indirect evidence and secondary analyses from the landmark SGLT2 trials as well as emerging data from recent studies including exclusively patients with diabetes and advanced CKD, indicate that the renal and cardiovascular benefits of SGLT2 inhibitors persist even in these patients. Although the use of SGLT2 inhibitors in patients with diabetes undergoing dialysis remains investigational, preliminary evidence from experimental and clinical studies seems promising in terms of multifaceted positive outcomes, including preservation of residual kidney function. Furthermore, the available data until now does not indicate an increase in risk in patients with diabetes and advanced CKD regarding acute impairment of kidney function or other adverse outcomes of interest including diabetic ketoacidosis, infections, fractures risk and amputations. The aim of this review is to present the current knowledge available on the utility of SGLT2 inhibitors in patients with diabetes and advanced CKD so as to provide a foundation for their implementation in clinical practice. Future experimental research shall further elucidate the pleiotropic effects of SGLT2 inhibitors so as to expand their indications in the setting of diabetes and advanced CKD. Finally, the results of ongoing clinical trials in patients with diabetes and kidney failure as well as in dialysis patients are much anticipated.