Early initiation of sodium‐glucose linked transporter inhibitors (SGLT‐2i) and associated metabolic and electrolyte outcomes in diabetic kidney transplant recipients

Abstract There is a paucity of data on the use of SGLT2 inhibitors on outcomes in kidney transplant recipients. There may be concern in initiating these agents, especially within the first year post‐transplant when renal function is more labile and immunosuppression more intense, due to a presumed high risk of urinary infections and acute kidney injury. This is a retrospective study on 50 kidney transplant recipients, half of whom were started on therapy within the first year of transplant. Over a follow‐up period of 6 months, overall patients had a statistically significant improvement in weight by −2.95 kg [SD 3.54, P = <.0001 (CI: 3.53, 1.50)] as well as hypomagnesemia 0.13 [SD 1.73, P = .0004 (CI: 0.06, 0.20)]. Overall insulin usage declined by −3.7 units [SD 22.8, P = .17]. 14% of patients had at least one urinary tract infection although this rate is not different (~20%) than that reported historically in this high‐risk population.

within the first year post-KT may provide significant benefits not only in glycemic control and metabolic side effects, but also in longterm hypomagnesemia associated with chronic calcineurin inhibitor utilization. Proper management of these complications early on post-transplant is needed to curb the progression to chronic disease and deleterious graft outcomes. This study aims to evaluate the metabolic, electrolyte and safety outcomes of early SGLT-2i utilization in KT recipients.
This was a single centre, retrospective, institutional review board approved study conducted in adult KT recipients who met our SGLT-2i initiation criteria. Patients were eligible if they had type II diabetes (pre-existing type 2 diabetes or PTDM); absence of AKI ≤30 days prior to initiation of therapy; freedom from any UTIs 6 months prior to therapy initiation; and an estimated glomerular filtration rate (eGFR) ≥30 mL/min at the time of initiation. Primary outcomes were changes in weight, insulin dosage, haemoglobin A1C (HgbA1C), magnesium concentration and safety outcomes including

Abstract
There is a paucity of data on the use of SGLT2 inhibitors on outcomes in kidney transplant recipients. There may be concern in initiating these agents, especially within the first year post-transplant when renal function is more labile and immunosuppression more intense, due to a presumed high risk of urinary infections and acute kidney injury. This is a retrospective study on 50 kidney transplant recipients, half of whom were started on therapy within the first year of transplant. Over a follow-up period of 6 months, overall patients had a statistically significant improvement in weight by  initiation. Therapy was discontinued in 9 patients: 5 (10%) due to UTIs, 1 (2%) developed a genital yeast infection, 1 (2%) due to native disease recurrence, 1 (2%) due to resolution of PTDM and 1 (2%) due to physician preference.

F I G U R E 1 Changes in magnesium and patient weight
Despite the nonsignificant short-term impact on diabetic management, our study illustrates that SGLT-2i can be used safely in the management of PTDM within KT recipients. Thereby increasing the oral antidiabetic treatment arsenal, as diet and oral medications have shown to be superior in obtaining glycemic control as compared to subcutaneous insulin among KT patients. 6 The small but statistically significant increment in magnesium concentrations might also provide benefit in KT recipients who experience chronic hypomagnesemia and decrease the progression of cardiovascular related outcomes. [1][2][3]7 Our incidence of adverse events particularly UTIs was comparable or even lower than those previously reported. [8][9][10] Some limitations to our study include the single-centre retrospective study design where results cannot be truly interpreted for causality and data collection was at the mercy of clinic visit documentations.
Future randomized research is needed to further validate the results.
Overall, the addition of SGLT-2i in select KT patients could provide benefit to common metabolic complications and electrolyte abnormalities such as weight gain and chronic hypomagnesaemia from prolonged immunosuppression exposure.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.