2025 Southeastern Residency Conference

Title: Use of SGLT2 Inhibitors in Heart Failure Patients Requiring Renal Replacement Therapy 
Authors: Meggie Gilkey, PharmD, Lindsay Reulbach, PharmD, BCPS, Jessica Howington, PharmD, Andi Ray, PharmD, BCCP
Background: Sodium-glucose cotransporter 2 (SGLT2) inhibitors, initially studied for type 2 diabetes, were found to reduce heart failure (HF) hospitalizations and cardiovascular death in both heart failure (HF) with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) populations. Additionally, they slow renal disease progression by 35–50%. As SGLT2 inhibitors become central to guideline-directed medical therapy (GDMT), their role in patients with concurrent HF and chronic kidney disease (CKD) has drawn attention. Concerns remain regarding use in severe CKD, especially among those on renal replacement therapy (RRT). To address this gap, we conducted a study evaluating the real-world safety and efficacy of SGLT2 inhibitors in HF patients requiring RRT.
Methods: A single-center, retrospective, observational, cohort study was conducted at Prisma Health Greenville Memorial Hospital. Patients 18 years or older admitted for HF who received an SGLT2 inhibitor and required RRT between October 1, 2023, and June 30, 2024, were included. Patients were monitored for outcomes over six months post-index hospitalization. HF-related admissions were identified using emergency department (ED) diagnoses, and RRT status was determined via nephrologist progress notes. Exclusion criteria included type 1 diabetes, pregnancy, non-HF SGLT2 inhibitor use, recent RRT initiation, RRT nonadherence, or malignancy. The primary outcome was SGLT2 inhibitor related adverse events. The secondary outcome assessed HF-related ED visits or hospitalizations.
Results: A total of 725 patients were screened and 7 were included. All patients received empagliflozin during their hospitalization. RRT was split between hemodialysis (57.1%) and peritoneal dialysis (42.8%). One patient (14.3%) experienced an SGLT2 inhibitor related adverse event, resulting in an ED visit 16 days post-index hospitalization. The adverse event was a urogenital infection in a patient with a known history of frequent urinary tract infections. No episodes of diabetic ketoacidosis, hypoglycemia, or hypotension were observed. No hospitalizations occurred due to SGLT2 inhibitor-related adverse events. Two HF-related hospitalizations occurred during the 6-month follow-up. One patient (14.3%) died during the study period, although the death was not related to SGLT2 inhibitor therapy or HF exacerbation.
 Conclusion: This real-world, observational study provides preliminary insight into the safety and efficacy of SGLT2 inhibitors in HF patients requiring RRT. Although limited by a small sample size, the findings suggest that SGLT2 inhibitors may be well tolerated, with minimal adverse events and potential benefit in reducing HF-related hospitalizations. However, due to the observational nature and limited scope of the study, no definitive conclusions can be drawn. Larger, controlled studies are needed to better understand the role of SGLT2 inhibitors in this high-risk population and to inform clinical decision-making with greater confidence.