Use of SGLT2 Inhibitors in Diabetic Renal Transplant Recipients: A Mixed Method Exploratory Exercise

Abstract

Background: Diabetes is the leading cause of end-stage renal disease (ESRD) worldwide. Also, diabetes is prevalent in kidney transplant recipients for nondiabetic reasons. Methodology: We used a mixed method methodology, including a case report, surveys of physicians’ opinions, and a review of the literature. Results: (A) A 58-year-old retired police officer was seen at the diabetes clinic in October 2015. His care was transferred from another physician who had relocated elsewhere. The patient’s medical history included type 2 diabetes for over 25 years, hyperlipidemia, hypertension, diabetic neuropathy, diabetic nephropathy, and diabetic retinopathy in addition to vitamin D deficiency and morbid obesity. He had received a renal transplant from a nonrelated live donor 7 years previously. His medications included sitagliptin 50 mg/day, gliclazide (modified release) 60–90 mg/day, metformin (extended release) 750 mg twice daily, and dapagliflozin 10 mg/day. We focus on the off-license use of dapagliflozin in a patient with a history of ESRD and renal transplantation. The lack of published experience with sodium-glucose cotransporter 2 (SGLT2) inhibitors in renal transplant recipients was discussed with him. “But I came to no harm,” was his reply. His records on renal function, hydration status, and glycemic control all seemed unaffected over the previous 2.5 years. He remains well till the time of this report. Serum electrolytes, creatinine, plasma albumin, hemoglobin, packed cell volume, and estimated glomerular filtration rate (eGFR) were not adversely affected. Glycated hemoglobin and fasting blood glucose were stable. Urine was consistently negative for ketones but loaded with glycosuria. It was agreed to continue with the same medication, observe the patient carefully, and seek for opinions of other physicians. (B) An online survey was conducted; the responses revealed that many physicians would use SGLT2 inhibitors in renal transplant recipients provided the renal function was satisfactory with an eGFR > 60. We have learned of an ongoing trial on SGLT2 inhibitors in renal transplant recipients. (C) A case series of 10 patients treated with canagliflozin showed reassuring findings. Conclusions: Despite the lack of formal trial evidence, the index case suggested the safe use of SGLT2 inhibitors by renal transplant recipients for a remarkably extended period of 2.5 years. Physicians seem willing to use SGLT2 inhibitors in this group of patients provided renal function is satisfactory.