Precision Use of SGLT2 Inhibitors in Glomerular Diseases

Authored by Sourabh Sharma, published on 2026-11-12 13:36:21.0

Adult With Established Glomerular CKD
- Confirm Chronicity, Diagnosis, Activity, eGFR, UACR/UPCR, and Volume
  - Active GN, AKI, Nephrotic Instability, or Intensive Immunosuppression?
    - Treat Active Disease and Defer SGLT2 Inhibitor
      - Reassess SGLT2 Eligibility After Clinical Stabilization
    - Continue Disease-Specific and RAS-Based Nephroprotective Therapy
      - Pregnancy, KRT, eGFR <20, or SGLT2 Hypersensitivity?
        
        Do Not Initiate SGLT2 Inhibitor
        
        Type 1 Diabetes or Prior Ketoacidosis?
        
        Avoid Routine Use; Require Specialist Risk Review
        
        Volume Depletion, Acute Illness, Fasting, or Active GU Infection?
        
        Correct Reversible Risks Before Initiation
        
        T2D, Heart Failure, or UACR ≥200 mg/g?
        
        Which Glomerular Disease Evidence Applies?
        
        IgAN: Add SGLT2 Inhibitor to Supportive Therapy
        
        For CKD Initiation (eGFR, mL/min/1.73 m²): Empagliflozin ≥20; Dapagliflozin ≥25
        
        Start Selected SGLT2 Inhibitor and Provide Hold Instructions
        
        Check eGFR and Volume Early; Track Proteinuria Longitudinally
        
        eGFR Fall >30%, Hypotension, Ketoacidosis, or Intolerance?
        
        Hold Therapy and Evaluate Volume, AKI, and Ketoacidosis
        
        Continue Until KRT or Intolerance; Reassess Kidney Risk
        
        FSGS: Use as Adjunct; Evidence Remains Limited
        
        For CKD Initiation (eGFR, mL/min/1.73 m²): Empagliflozin ≥20; Dapagliflozin ≥25
        
        Start Selected SGLT2 Inhibitor and Provide Hold Instructions
        
        Check eGFR and Volume Early; Track Proteinuria Longitudinally
        
        eGFR Fall >30%, Hypotension, Ketoacidosis, or Intolerance?
        
        Hold Therapy and Evaluate Volume, AKI, and Ketoacidosis
        
        Continue Until KRT or Intolerance; Reassess Kidney Risk
        
        Other Stable Disease: Use General CKD Evidence Cautiously
        
        For CKD Initiation (eGFR, mL/min/1.73 m²): Empagliflozin ≥20; Dapagliflozin ≥25
        
        Start Selected SGLT2 Inhibitor and Provide Hold Instructions
        
        Check eGFR and Volume Early; Track Proteinuria Longitudinally
        
        eGFR Fall >30%, Hypotension, Ketoacidosis, or Intolerance?
        
        Hold Therapy and Evaluate Volume, AKI, and Ketoacidosis
        
        Continue Until KRT or Intolerance; Reassess Kidney Risk
        
        eGFR 20–44 With UACR <200 mg/g?
        
        Selected Patients: Use SGLT2 Inhibitor With Nephrologist Judgment
        
        For CKD Initiation (eGFR, mL/min/1.73 m²): Empagliflozin ≥20; Dapagliflozin ≥25
        
        Start Selected SGLT2 Inhibitor and Provide Hold Instructions
        
        Check eGFR and Volume Early; Track Proteinuria Longitudinally
        
        eGFR Fall >30%, Hypotension, Ketoacidosis, or Intolerance?
        
        Hold Therapy and Evaluate Volume, AKI, and Ketoacidosis
        
        Continue Until KRT or Intolerance; Reassess Kidney Risk
        
        Do Not Routinely Initiate; Continue Risk-Based Follow-Up
        
        T2D, Heart Failure, or UACR ≥200 mg/g?
        
        Which Glomerular Disease Evidence Applies?
        
        IgAN: Add SGLT2 Inhibitor to Supportive Therapy
        
        For CKD Initiation (eGFR, mL/min/1.73 m²): Empagliflozin ≥20; Dapagliflozin ≥25
        
        Start Selected SGLT2 Inhibitor and Provide Hold Instructions
        
        Check eGFR and Volume Early; Track Proteinuria Longitudinally
        
        eGFR Fall >30%, Hypotension, Ketoacidosis, or Intolerance?
        
        Hold Therapy and Evaluate Volume, AKI, and Ketoacidosis
        
        Continue Until KRT or Intolerance; Reassess Kidney Risk
        
        FSGS: Use as Adjunct; Evidence Remains Limited
        
        For CKD Initiation (eGFR, mL/min/1.73 m²): Empagliflozin ≥20; Dapagliflozin ≥25
        
        Start Selected SGLT2 Inhibitor and Provide Hold Instructions
        
        Check eGFR and Volume Early; Track Proteinuria Longitudinally
        
        eGFR Fall >30%, Hypotension, Ketoacidosis, or Intolerance?
        
        Hold Therapy and Evaluate Volume, AKI, and Ketoacidosis
        
        Continue Until KRT or Intolerance; Reassess Kidney Risk
        
        Other Stable Disease: Use General CKD Evidence Cautiously
        
        For CKD Initiation (eGFR, mL/min/1.73 m²): Empagliflozin ≥20; Dapagliflozin ≥25
        
        Start Selected SGLT2 Inhibitor and Provide Hold Instructions
        
        Check eGFR and Volume Early; Track Proteinuria Longitudinally
        
        eGFR Fall >30%, Hypotension, Ketoacidosis, or Intolerance?
        
        Hold Therapy and Evaluate Volume, AKI, and Ketoacidosis
        
        Continue Until KRT or Intolerance; Reassess Kidney Risk
        
        eGFR 20–44 With UACR <200 mg/g?
        
        Selected Patients: Use SGLT2 Inhibitor With Nephrologist Judgment
        
        For CKD Initiation (eGFR, mL/min/1.73 m²): Empagliflozin ≥20; Dapagliflozin ≥25
        
        Start Selected SGLT2 Inhibitor and Provide Hold Instructions
        
        Check eGFR and Volume Early; Track Proteinuria Longitudinally
        
        eGFR Fall >30%, Hypotension, Ketoacidosis, or Intolerance?
        
        Hold Therapy and Evaluate Volume, AKI, and Ketoacidosis
        
        Continue Until KRT or Intolerance; Reassess Kidney Risk
        
        Do Not Routinely Initiate; Continue Risk-Based Follow-Up

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