February 2025: Long-Term Effects of Empagliflozin in Patients with Chronic Kidney Disease
The issue
A two‑year course of the SGLT2 inhibitor empagliflozin continued to protect kidneys and hearts for up to a year after the drug was stopped, cutting the combined risk of kidney progression or cardiovascular death by about 20 %.
What do I need to know?
The EMPA‑KIDNEY trial enrolled 6,609 adults with chronic kidney disease (CKD) of varied causes and randomized them to empagliflozin 10 mg daily or placebo. After a median two years on treatment plus two more years of observation, 26 % of the empagliflozin group versus 30 % of the placebo group experienced kidney failure progression or cardiovascular death (hazard ratio 0.79, 95 % CI 0.72–0.87). Benefits persisted after discontinuation (post‑trial HR 0.87). Empagliflozin also lowered standalone kidney‑progression events by 21 % (23.5 % vs 27.1 %) and reduced end‑stage kidney disease from 11.3 % to 9.0 %. Serious side‑effects and overall mortality were similar between groups, with no increase in non‑cardiovascular deaths.
Potential risk of CKD progression
CKD stage 2–3a (eGFR 45–60 ml/min) without heavy proteinuria or diabetes complications.
Recommended Actions
Monitor eGFR and urine albumin every 6–12 months.
Optimize blood‑pressure and glucose targets; encourage exercise and salt restriction.
Ask whether starting empagliflozin early could add long‑term protection.
Imminent risk of CKD progression
eGFR 30–44 ml/min or persistent albumin‑to‑creatinine ratio ≥ 200 mg/g.
Recommended Actions
Review eligibility for empagliflozin and ensure renin–angiotensin system blockers are at goal dose.
Check potassium, volume status, and potential drug interactions within four weeks of starting therapy.
Schedule dietitian consult for protein and sodium guidance.
Confirmed high‑risk CKD
eGFR < 30 ml/min, rapidly falling (> 5 ml/min/year), or recent hospitalization for heart failure.
Recommended Actions
Continue empagliflozin unless contraindicated; consider adding finerenone or GLP‑1 agonist per guidelines.
Arrange vascular access planning and transplant education early.
Monitor eGFR, potassium, and weight monthly; address volume overload and anemia promptly.
What can I do?
Bring your latest lab results and ask the kidney team, “Am I at potential, imminent, or confirmed risk, and how does empagliflozin fit my plan?” Take the pill once daily, stay hydrated, and report dizziness or genital discomfort. Keep blood pressure below 130/80 mm Hg, limit salt to two teaspoons per day, and increase walking to 30 minutes most days. Caregivers can track weight and blood tests in a notebook so small changes trigger timely adjustments.
