Continuation of sodium-glucose co-transporter 2 inhibitors in advanced chronic kidney disease: a retrospective study with inverse probability of treatment weighting analysis.

BACKGROUND: Sodium-glucose co-transporter 2 inhibitors (SGLT2i) slow the progression of chronic kidney disease (CKD). However, the evidence to support the continuation of SGLT2i when estimated glomerular filtration rate (eGFR) falls below 20 mL/min/1.73 m2 is limited. METHODS: Between 2015 and 2021, we identified 1011 CKD patients who received SGLT2i for at least 3 months and had eGFR that had progressed to ≤20 mL/min/1.73 m2; 585 were continued with SGLT2i (Continuation group), and 426 had SGLT2i stopped (Discontinuation group). Inverse probability of treatment weighting (IPTW) was applied to minimize baseline differences between the two groups. The primary outcome was dialysis-free survival. RESULTS: The median follow-up was 14.3 months (interquartile range 8.7-21.8 months). The IPTW-adjusted 2-year dialysis-free survival rates of the Discontinuation and Continuation groups were 41.7% and 58.9%, respectively (weighted log rank test, P < .0001). Continuation of SGLT2i was associated with 39.9% reduction in risk of progression to dialysis or death (weighted hazard ratio 0.601, 95% confidence interval 0.241-0.525). The IPTW-adjusted 2-year patient survival rates of the Discontinuation and Continuation groups were 40.6% and 71.7%, respectively (P < .0001). With multivariable Cox regression model, the Continuation group had a 46.8% (95% confidence interval 29.8%-59.7%) reduction in risk of death. The result remained similar when a propensity score-matched nested cohort was used for analysis. CONCLUSION: In CKD patients who received SGLT2i therapy, continuation of the SGLT2i therapy after the eGFR fell below 20 mL/min/1.73 m2 was associated with a higher dialysis-free survival and patient survival than discontinuation of SGLT2i. Our result suggests the practice of continuation with SGLT2i in this setting.