Use of ISGLT2 in kidney transplant recipients without diabetes mellitus

Abstract

Introduction

Kidney transplant (KT) recipients have a very high cardiovascular and renal risk. Sodium–glucose cotransporter-2 inhibitors (iSGLT2) have demonstrated cardiorenal benefits in non-transplanted populations with chronic kidney disease, both diabetic and non-diabetic, but evidence in KT recipients remains scarce. There is an unmet clinical need for additional nephroprotective and cardiometabolic interventions in KT without diabetes mellitus (DM). We aimed to assess safety, renal function and metabolic effects of SGLT2i in non-diabetic KT recipients.

Methods

Retrospective single-centre observational study including 28 non-diabetic KT recipients (no pre-existing DM or post-transplant DM) from the University Hospital of Salamanca treated with SGLT2i (2023–2025). We analysed renal function trajectories (serum creatinine, eGFR CKD-EPI, urine protein/creatinine ratio [PCR] and urine albumin/creatinine ratio [ACR), lipid profile, electrolytes, HbA1c, immunosuppression, adverse events and acute rejection, with follow-up at 1, 6 and 12 months.

Results

Mean age at SGLT2i initiation was 57 ± 13 years; 89,3% were men. The main indication was non-nephrotic proteinuria. After an initial eGFR decline, renal function subsequently stabilised. PCR and ACR decreased significantly at one year. Body mass index and total cholesterol also declined. There were no clinically relevant changes in immunosuppressant levels and no increase in rejection episodes. Diarrhoea and urinary tract infections (7%) were the most frequent adverse events, without euglycaemic ketoacidosis.

Conclusions

SGLT2i therapy showed acceptable safety and a possible reno-metabolic benefit in non-diabetic KT recipients. Controlled trials with longer follow-up are required to determine the robustness of this indication.