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Correspondence to: S Li [email protected], B Ponte [email protected], T Agoritsas [email protected]
Why is the guideline needed?
Chronic kidney disease (CKD) is characterised by abnormalities of kidney structure or function, present for a minimum of three months, and is classified based on aetiology, glomerular filtration rate (GFR), and degree of albuminuria.1 CKD affects approximately 850 million individuals internationally, is the tenth leading cause of death, and is projected to be the fifth leading cause by 2050.234 Although clinical trajectories vary across individuals, CKD is generally progressive, with declining GFR and progressive albuminuria associated with an increasing risk of cardiovascular complications, kidney failure, and premature death.56
For a long time, therapies to slow progression of kidney disease and improve long term prognosis of adults living with CKD were lacking. Sodium-glucose co-transporter-2 (SGLT-2) inhibitors have emerged—alongside renin-angiotensin system inhibitors, glucagon-like peptide 1 agonists, and non-steroidal mineralocorticoid receptor antagonists—as therapies with potential cardiovascular and kidney protective effects among individuals with type 2 diabetes and CKD.7 Recently, two randomised trials have demonstrated similar cardiovascular and kidney benefits with the use of SGLT-2 inhibitors among non-diabetic individuals with CKD at varying GFRs and degrees of albuminuria.89
Previous guidelines from Kidney Disease: Improving Global Outcomes (KDIGO) recommended the use of SGLT-2 inhibitors for patients with type 2 diabetes, CKD, and an estimated GFR of ≥20 mL/min per 1.73 m2.10 Their more recent guidance provide recommendations for SGLT-2 inhibitors more broadly for adults with CKD irrespective of diabetes status; however, recommendations are limited to specific risk groups (that is, an estimated GFR ≥20 mL/min per 1.73 m2 with urine albumin to creatinine ratio (ACR) ≥20 mg/mmol (≥200 mg/g) with concurrent heart failure; or with an estimated GFR 20-45 mL/min per 1.73 m2 with urine ACR <20 mg/mmol).11 Moreover, these recommendations are primarily informed by a systematic review and meta-analysis of large double-blind, placebo-controlled trials of at least six months duration evaluating SGLT-2 inhibitors across disease populations including CKD. The review included only four large trials including adults with CKD and did not account for the entirety of existing randomised trial evidence applicable to the CKD population. The review and practice guideline did not take into account treatment...