Sodium-Glucose Cotransporter-2 Inhibitors in Critically Ill Patients and Acute Kidney Injury: Clinical Considerations
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Abstract
Acute kidney injury (AKI) is a severe complication, affecting up to 50% of critically ill patients. The advent of sodium-glucose cotransporter-2 (SGLT2) inhibitors has challenged traditional paradigms of renoprotection. Their mechanisms include restoration of tubuloglomerular feedback, metabolic reprogramming toward ketone utilization, anti-inflammatory actions, and modulation of the sympathetic nervous system. Emerging evidence suggests a complex risk–benefit profile for SGLT2 inhibitors in critical illness. Observational studies consistently show associations with reduced ICU admissions, lower infection rates, and improved survival. However, interventional studies indicate nuanced effects, including potential increases in vasopressor requirements in septic patients. The ongoing PREVENTS-AKI trial, specifically designed for ICU patients, will provide definitive evidence to guide clinical practice. The use of SGLT2 inhibitors in this vulnerable population requires careful consideration of unique safety concerns, including euglycemic diabetic ketoacidosis, increased vasopressor requirements, electrolyte disturbances, volume depletion, and genitourinary infections. Implementation should follow structured protocols with a thorough baseline assessment, daily monitoring, and clear discontinuation criteria. Until more robust evidence emerges, SGLT2 inhibitors represent a promising but cautiously applied option for AKI prevention in selected critically ill patients.
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