*Purpose: Metabolic complications such as post-transplant diabetes (PTDM) are quickly becoming the leading causes of death in kidney transplant (KT) recipients. The use of Sodium Glucose Linked Transporter Inhibitors (SGLT-2i) among non-transplant diabetic patients with chronic kidney disease (CKD) have demonstrated reduced cardiovascular mortality and delayed CKD progression. Currently, there is no data on the use of SGLT-2 in KT recipients early post-transplant where renal function may be lower and labile, and immunosuppression more intense. In addition, there is a perceived heightened risk of known SGLT-2i associated adverse effects like urinary tract infections (UTIs), amputations and pre-renal acute kidney injury (AKI) in KT recipients. We aimed to bridge this knowledge gap and report our early experience with SGLT-2i at our center.

*Methods: This was a single center, retrospective study, conducted in adult KT recipients who met SGLT-2i initiation criteria at our center. Patients were eligible if they had type II diabetes (pre-existing or new onset post-transplant); no AKI ≤30 days prior to drug initiation; and an estimated glomerular filtration rate (eGFR) > 30 mL/min. Primary outcomes were rates of treated UTIs, diabetic ketoacidosis (DKA), amputations, and hospitalizations due to AKI. Secondary outcomes included changes in weight, insulin dosage, eGFR, and hemoglobin A1C (HgbA1C). Choice of the specific SGLT-2i agent was based upon insurance preference.

*Results: 38 patients met criteria for enrollment. The median time to initiation from transplant was 229 days (IQR 119-479). The mean eGFR at the time of initiation was 66.4 mL/min (SD: 21.9) with 5 (13%) patients beginning therapy with an eGFR of 30-45 mL/min. Of those, 29 (76%) received empagliflozin, 7 (18%) canagliflozin, and 2 (6%) dapagliflozin. Therapy was discontinued in 6 (16%) patients: 3 (8%) developed UTIs on average 30 days after initiation of therapy resulting to 1 UTI per 117 patient years, 1 (3%) started ketogenic diet, 1 (3%) due to decline in renal function, and 1 (3%) due to physician preference. None of the other patients experienced DKA, amputations, or AKI episodes. There were significant improvement in weight by -1.27 kg [(SD 2.68, p=0.004 (CI:-2.09, -0.35)] and HgbA1c by -1% (SD 1.73, p=0.012 over a mean follow up time of 105 days. The median change in eGFR and insulin use were -2.01 mL/min, p=0.39 (CI: -6.71, 2.68) and -3.7 units, p=0.17 (CI: -11.7, 4.2) respectively.

*Conclusions: In this first report, we found a clinically non-significant risk of adverse events with early SGLT2 inhibitor initiation post-kidney transplant. Early trends point towards both good efficacy and an improved metabolic profile.

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