SGLT2 inhibitors

FMT in HFrEF · Class IFMT in HFpEF · Class I

Removal by dialysis

What each drug's prescribing information says about removal by (haemo)dialysis. Where the label is silent, this page says so rather than inferring from protein binding.

DapagliflozinRemoval not studied
- “The removal of dapagliflozin by hemodialysis has not been studied.”
  FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· 10 OVERDOSAGE Source
EmpagliflozinRemoval not studied
- “Removal of empagliflozin by hemodialysis has not been studied.”
  JARDIANCE (empagliflozin) PI, Boehringer Ingelheim (2026)· 10 OVERDOSAGE Source

After starting: what a change in creatinine, eGFR or potassium means

An eGFR fall to below 20: look for other causes; continuation is advised, with close monitoring. Watch for dehydration, hypotension and pre-renal kidney failure with diuretics, especially in older or frail patients.

“eGFR drops <20 mL/min/1.73 m2: seek other causes. Continuation of SGLT2-I is advised but may be after close monitoring.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 20, Table S9 Source
“Diuretic doses along with fluid intake should be balanced in order to avoid dehydration, symptomatic hypotension, and pre-renal kidney failure.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 20, Table S9 Source

A hemodynamic eGFR dip of up to 30% after starting an SGLT2 inhibitor, RAAS inhibitor, MRA or ARNI is expected and should not lead to discontinuation; above 30%, look for other causes of AKI (KDIGO). ESC accepts a creatinine rise of less than 50% above baseline as long as eGFR stays above 15.

“Hemodynamic fluctuations in eGFR up to 30% can be seen and should not lead to discontinuation”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 10
“If >30%, other causes of AKI should be evaluated”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 10
“An increase in serum creatinine of <50% above baseline, as long as eGFR remains >15 mL/min/1.73 m2, is considered acceptable.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 66, Section 10.3 Source
“Worsening kidney function alone is not an independent determinant of outcomes in patients with acute HF.”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 11

Drugs and doses

Drug	Brands	Start	Target	Kidney dosing
Dapagliflozin	Farxiga, Forxiga	10 mg o.d.	10 mg o.d.	No dose adjustment at any eGFR (always 10 mg o.d. for HF). FDA label: initiation not recommended at eGFR <25; if eGFR falls below 25 on treatment, may continue 10 mg o.d. Not studied for initiation <25 or in dialysis; DAPA-CKD/DELIVER did not require stopping if eGFR fell <25 or dialysis started. Glycaemic indication limited to eGFR >=45 (irrelevant for HF benefit).
Empagliflozin	Jardiance	10 mg o.d.	10 mg o.d.	No dose adjustment for HF (10 mg o.d.; 25 mg only for extra glycaemic control). The FDA label gives NO eGFR floor for the HF or CKD indications (only glycaemic use not recommended <30); HF/CKD trials enrolled eGFR >=20 and did not require stopping if eGFR fell <20 or dialysis started. ESC Table S9 / ESC CVD-CKD: do not initiate <20.
Sotagliflozin (SGLT1/2 inhibitor)	Inpefa	200 mg o.d.	400 mg o.d.	FDA-approved for HF (any LVEF) but NOT named in ESC 2026 FMT (ESC names dapagliflozin/empagliflozin only; sotagliflozin mentioned only for in-hospital initiation evidence from SOLOIST-WHF). Label has no explicit eGFR initiation floor; trials (SOLOIST-WHF, SCORED) did not enrol eGFR <25 or dialysis and stopped drug if eGFR fell <15 or chronic dialysis began. More volume-related AEs at eGFR <30. Exposure up to 170% higher in moderate renal impairment; label allows down-titration to 200 mg.

Status by kidney stage

Stage	Initiate	Continue
G1	Recommended Class I FMT in symptomatic HF regardless of LVEF; standard 10 mg o.d. dosing (dapagliflozin, empagliflozin).	Recommended Continue indefinitely at 10 mg o.d.
G2	Recommended Class I FMT (ESC 2026, AHA 2022 for HFrEF); no renal dose adjustment.	Recommended Continue indefinitely at 10 mg o.d.
G3a	Recommended Class I in HF with CKD (ESC CVD-CKD 2026, eGFR >=20); assess volume status first because eGFR <60 raises volume-depletion risk.	Recommended Continue; an early eGFR dip is expected and is not a reason to stop.
G3b	Recommended Class I; well represented in DAPA-HF (eGFR >=30), EMPEROR (>=20) and DAPA-CKD/EMPA-KIDNEY. Assess volume status before starting.	Recommended Continue; tolerate early eGFR dip.
G4	Use with caution Split stage: recommended at eGFR >=25 for dapagliflozin (label) and >=20 for empagliflozin (trial floor / ESC CVD-CKD Class I); initiation not recommended below 20 (ESC Table S9 lists eGFR <20 as a contraindication) and dapagliflozin label advises against starting <25. Use thresholds[] for the exact cut-off.	Recommended Continue if eGFR falls into G4 or below 20 (FDA dapagliflozin label; ESC CVD-CKD IIa; ESC Table S9; KDIGO PP 3.7.1).
G5	Not recommended Do not initiate at eGFR <15 (no trial data; ESC Table S9 eGFR <20 contraindication; ESC CVD-CKD: evidence insufficient <20).	Use with caution May continue if already established and tolerated and KRT not started (ESC CVD-CKD, KDIGO); dapagliflozin label permits continuation below 25 without a lower bound. ESC 2026 HF: temporary discontinuation may be needed with AKI and eGFR <15. Sotagliflozin was stopped at eGFR <15 in its trials.
dialysis	Not recommended No trial enrolled dialysis patients; ESC CVD-CKD states evidence is insufficient to support initiation. Dedicated RCTs (RENAL LIFECYCLE, DAPA-HD) are ongoing/unreported.	Not recommended Guidelines (ESC CVD-CKD 2026, KDIGO 2024) support continuation only until KRT is initiated. FDA dapagliflozin/empagliflozin labels note trial participants were not required to stop at dialysis initiation, and a post-hoc DAPA-CKD analysis suggests lower mortality, but this is hypothesis-generating. Conservative default: stop at maintenance dialysis; flag for owner review.
aki	Use with caution Defer initiation until volume depletion is corrected and kidney function is stable (labels). Exception: in congested DHF with eGFR >20, early in-hospital initiation is recommended and a creatinine rise during decongestion is not by itself AKI requiring deferral.	Use with caution Temporary hold may be needed in AKI (especially with eGFR <15 or volume depletion/acute illness); restart when stable. A transient eGFR dip after initiation is expected and should not prompt interruption.
transplant	Use with caution Very limited evidence: no HF outcome trial in kidney transplant recipients; small RCT (n=44, post-transplant diabetes) and observational data suggest safety. ESC CVD-CKD: may be considered in transplant recipients with T2D (extrapolated). Use the eGFR rules of the native-kidney stages plus infection vigilance.	Use with caution Continue with caution (genitourinary infection risk under immunosuppression); RENAL LIFECYCLE includes a transplant stratum (eGFR <=45) and is unreported.

Cutoffs recorded from the sources

egfr < 25 mL/min/1.73m2 → not-recommended (initiate; dapagliflozin)
“Initiation with FARXIGA is not recommended in patients with an eGFR less than 25 mL/min/1.73 m2.” — fda-dapagliflozin, Section 2.3 Recommended Dosage for Other Indications in Adults
egfr < 25 mL/min/1.73m2 → allowed (continue; dapagliflozin)
“If the eGFR falls below 25 mL/min/1.73 m2 while receiving treatment with FARXIGA, patients may continue FARXIGA 10 mg orally once daily to reduce the risk of eGFR decline, ESKD, CV death and hHF.” — fda-dapagliflozin, Section 2.3 Recommended Dosage for Other Indications in Adults
egfr < 20 mL/min/1.73m2 → not-recommended (initiate; dapagliflozin, empagliflozin)
“eGFR <20 mL/min/1.73 m2. Currently not approved for type 1 diabetes due to risk of ketoacidosis.” — esc2026-supp, p. 19 (Table S9, Contraindications)
egfr >= 20 mL/min/1.73m2 → recommended (initiate; dapagliflozin, empagliflozin)
“Treatment with an SGLT2 inhibitor is recommended in patients with HF and CKD with eGFR ≥20 mL/min/1.73 m2 irrespective of LVEF, to reduce the risk of (repeated) HF hospitalization and cardiovascular death.” — esc2026-ckd, p. 39 (Recommendation Table 15, Class I A)
egfr < 20 mL/min/1.73m2 → recommended (continue; dapagliflozin, empagliflozin)
“Continuation of a SGLT2 inhibitor should be considered in patients with HF and CKD in whom the eGFR progresses to <20 mL/min/ 1.73 m2” — esc2026-ckd, p. 44 (Recommendation Table 18, Class IIa C)
egfr < 15 mL/min/1.73m2 → caution (hold; dapagliflozin, empagliflozin, sotagliflozin)
“However, temporary discontinuation of MRAs/ARNIs/ACE-Is/ARBs and SGLT2-Is may be needed in cases with acute kidney injury and eGFR <15 mL/min/1.73 m2.” — esc2026, p. 35
creatinine_rise_pct < 50 % above baseline → allowed (continue; dapagliflozin, empagliflozin, sotagliflozin)
“An increase in serum creatinine of <50% above baseline, as long as eGFR remains >15 mL/min/1.73 m2, is considered acceptable.” — esc2026, p. 66
other > 30 % eGFR decline from baseline → caution (continue; dapagliflozin, empagliflozin, sotagliflozin)
“Hemodynamic fluctuations in eGFR up to 30% can be seen and should not lead to discontinuation” — kdigo2026-hf, p. 10
egfr < 45 mL/min/1.73m2 → not-recommended (initiate; dapagliflozin)
“FARXIGA is not recommended for use to improve glycemic control in patients with type 2 diabetes mellitus with an eGFR less than 45 mL/min/1.73 m2.” — fda-dapagliflozin, Section 2.2 Recommended Dosage for Glycemic Control
egfr < 30 mL/min/1.73m2 → not-recommended (initiate; empagliflozin)
“Use for glycemic control is not recommended in patients with an eGFR less than 30 mL/min/1.73 m2” — fda-empagliflozin, Section 2.1 Testing Prior to Initiation of JARDIANCE
egfr < 25 mL/min/1.73m2 → caution (initiate; sotagliflozin)
“Efficacy and safety studies with INPEFA did not enroll patients with an eGFR less than 25 mL/min/1.73 m2 or on dialysis.” — fda-sotagliflozin, Use in Specific Populations 8.6 Renal Impairment
egfr < 15 mL/min/1.73m2 → not-recommended (continue; sotagliflozin)
“After starting therapy in these studies, patients were discontinued if eGFR fell below 15 mL/min/1.73 m2 or were initiated on chronic dialysis.” — fda-sotagliflozin, Use in Specific Populations 8.6 Renal Impairment
sbp < 95 mmHg → caution (initiate; dapagliflozin, empagliflozin)
“Symptoms of hypotension and a systolic blood pressure <95 mmHg.” — esc2026-supp, p. 19 (Table S9, Cautions/seek specialist advice)
sbp < 100 mmHg → caution (initiate; sotagliflozin)
“Patients were randomized to treatment if they met the following criteria for clinical stability: no need for oxygen therapy, a systolic blood pressure of at least 100 mmHg, no need for intravenous inotropic or vasodilator therapy (excluding nitrates) and transitioned from intravenous to oral diuretic therapy.” — fda-sotagliflozin, Clinical Studies 14.1 SOLOIST Study
other >= 3 days before surgery or prolonged fasting → caution (hold; dapagliflozin, empagliflozin, sotagliflozin)
“Withhold FARXIGA for at least 3 days, if possible, prior to surgery or procedures associated with prolonged fasting. Resume FARXIGA when the patient is clinically stable and has resumed oral intake” — fda-dapagliflozin, Section 2.4 Temporary Interruption for Surgery
other < 14 days since temporary discontinuation (restart at previous dose) → allowed (initiate; dapagliflozin, empagliflozin)
“If SGLT2-I has been temporarily discontinued for less than 14 days, it should, in most cases, be safe to initiate directly at the previously tolerated doses in stable patients.” — esc2026-supp, p. 19 (Table S9)

Trial evidence (informational)

DAPA-HF · HFrEF (LVEF <=40%), NYHA II-IV, eGFR >=30
CV death, HF hospitalisation or urgent HF visit: HR 0.74 (95% CI 0.65-0.85)
“386(11.6) | 386(11.6) 502(15.6) | 502(15.6) 0.74(0.65, 0.85) | 0.74(0.65, 0.85)” — fda-dapagliflozin, Clinical Studies 14.5, Table 17 (DAPA-HF column)
EMPEROR-Reduced · HFrEF (LVEF <=40%), NYHA II-IV, eGFR >=20
CV death or HF hospitalisation: HR 0.75 (95% CI 0.65-0.86)
“CV death or HHFa | 462 (24.7%) | 361 (19.4%) | 0.75 (0.65, 0.86) | <0.0001 |” — fda-empagliflozin, Clinical Studies 14.4, Table 16
DAPA-HF + EMPEROR-Reduced · HFrEF
CV death or HF hospitalisation: ~25% relative reduction
“In the DAPA-HF and EMPEROR-Reduced trials, SGLT2i compared with placebo reduced the composite of cardiovascular death or HF hospitalization by approximately 25% (1,2,9).” — aha2022, p. 45
EMPEROR-Preserved · HF with LVEF >40%, eGFR >=20
CV death or HF hospitalisation: HR 0.79 (95% CI 0.69-0.90)
“At a median follow-up of 26.2 months, empagliflozin reduced the primary endpoint (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.69–0.90; P < .001).” — esc2023-update, p. 6
DELIVER · HF with LVEF >40%, eGFR >=25
CV death or worsening HF: HR 0.82 (95% CI 0.73-0.92)
“Dapagliflozin reduced the primary endpoint of CV death or worsening HF (HF hospitalization or urgent HF visit) (HR 0.82, 95% CI 0.73– 0.92; P < .001).” — esc2023-update, p. 6
SOLOIST-WHF · T2D with recent worsening HF (any LVEF), started in hospital or early after discharge
Total CV death, HF hospitalisation and urgent HF visits: HR 0.67 (95% CI 0.53-0.85)
“INPEFA was superior to placebo in reducing the risk of the primary composite endpoint (Hazard Ratio [HR] 0.67 [95% confidence interval (CI) 0.53, 0.85]; p = 0.001).” — fda-sotagliflozin, Clinical Studies 14.1 SOLOIST Study
EMPULSE · Hospitalised acute HF after stabilisation
Hierarchical clinical benefit at 90 days: Significantly higher chance of clinical benefit
“The EMPULSE trial demonstrated that in-hospital initiation of 10 mg empagliflozin resulted in significantly higher chances of clinical benefit, at 90 days” — esc2026, p. 50
Cross-trial lifetime analysis (DELIVER, FINEARTS-HF, PARAGON-HF) · HFmrEF/HFpEF
CV death or first worsening HF event; event-free years: SGLT2i + finerenone HR 0.69 (0.59-0.81); +3.6 event-free years at age 65
“With long-term use, combined SGLT2i and nsMRA therapies in a 65-year-old patient with HFmrEF/HFpEF, or combined SGLT2i, nsMRA and ARNI therapies in a 65-year-old patient with an LVEF <60%, were projected to afford 3.6 (2.0–5.2) or 4.9 (2.5–7.3) additional years free from cardiovascular death or a heart failure event, respectively.” — vaduganathan2026, p. 1
DAPA-CKD (dialysis-initiators, post hoc) · CKD patients who started dialysis during DAPA-CKD (n=167)
All-cause mortality after dialysis initiation: aHR 0.47 (95% CI 0.23-0.98); non-randomised, hypothesis-generating
“Participants in the dapagliflozin group had significantly lower all-cause mortality (adjusted hazard ratio [aHR] 0.47, 95% CI: 0.23–0.98, Figure 1).” — bakker2026, DAPA-CKD dialysis post-hoc analysis, results

Acute kidney injury

SGLT2i reduce AKI risk overall (~23% in SMART-C; ESC CVD-CKD 'around one-quarter'), but labels warn of volume depletion and post-marketing AKI, so correct volume depletion before starting and consider a temporary hold in AKI (ESC 2026: may be needed with AKI and eGFR <15) or acute illness with poor oral intake (sick-day rules), restarting when stable. The expected haemodynamic eGFR dip after initiation is not AKI and should not prompt interruption. In congested DHF, worsening creatinine during successful decongestion is not associated with poor outcomes, and early in-hospital initiation is recommended.

“In addition to reducing kidney failure and cardiovascular risk, SGLT2 inhibitors reduce the risk of reported AKI by around one-quarter overall in the studied populations.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 29 Source
“Thus, a transient decrease in kidney function after the initiation of ACE-Is/ARNIs/ARBs and MRAs or SGLT2-Is should not prompt their interruption.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 66 Source
“Changes that do not fit this pattern should prompt further evaluation to exclude the possibility of acute kidney injury.”
INPEFA (sotagliflozin) PI, Lexicon (2026)· Adverse Reactions 6.1, Increase in Serum Creatinine and Decrease in eGFR Source
“None of the large trials demonstrated an increased risk of AKI in people treated with SGLT2i (Figure 22)”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 102 Source
“Diuretic doses along with fluid intake should be balanced in order to avoid dehydration, symptomatic hypotension, and pre-renal kidney failure.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 20 (Table S9, Problem solving) Source

Dialysis

No completed outcome RCT in dialysis. All pivotal trials excluded dialysis at entry (labels 8.6). Dapagliflozin/empagliflozin labels: trial participants were not required to stop when dialysis started; ESC CVD-CKD 2026 and KDIGO 2024 support continuation only until KRT is initiated (ESC: 'reviewed around the time of needing KRT'). Post-hoc DAPA-CKD: 167 participants started dialysis; adjusted all-cause mortality HR 0.47 (95% CI 0.23-0.98) favouring dapagliflozin, hypothesis-generating only. RENAL LIFECYCLE (dapagliflozin vs placebo; eGFR <=25, dialysis >=3 months, transplant eGFR <=45; ~1500 patients) and DAPA-HD (haemodialysis, LV mass endpoint, n=220) have no published results as of 2026-10-09. Conservative default: do not initiate; stop at start of maintenance dialysis unless the owner chooses label-based continuation.

Trials: DAPA-CKD dialysis post hoc (Bakker 2026), HELD-HF (henagliflozin in dialysis HFpEF), Empagliflozin in PD with HF (Japanese crossover RCT, reviewed by Minutolo 2026), SGLT2i in PD with T2D (Chen 2026, target-trial emulation), DAPA-HD (design paper; results pending), RENAL LIFECYCLE (results pending)

“The effects of SGLT2 inhibition at lower eGFR than studied in the reported trials and in patients requiring KRT are being assessed in the ongoing RENAL LIFECYCLE trial (NCT05374291).”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 29 Source
“Once enrolled, adult patients in the EMPA-REG OUTCOME, EMPEROR-Reduced, EMPEROR-Preserved, and EMPA-KIDNEY trials were not required to discontinue therapy for worsening of eGFR to less than 20 mL/min/1.73 m2 or initiation of dialysis”
JARDIANCE (empagliflozin) PI, Boehringer Ingelheim (2026)· Use in Specific Populations 8.6 Renal Impairment Source
“SGLT2i continue until dialysis or transplant”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 91 (Figure) Source
“Out of the total study population of the DAPA-CKD trial (n = 4304), 167 participants initiated dialysis during the study.”
Bakker WM et al. Efficacy and safety of dapagliflozin in patients receiving dialysis: a post-hoc analysis of the DAPA-CKD trial. Clin Kidney J 2026 (PMC13339949) (2026)· DAPA-CKD dialysis post-hoc analysis, results Source
“Of course, these data should be interpreted with caution as the number of patients included in this analysis was low, and due to the non-randomized post-hoc design characteristics of subjects at start of dialysis differed between both study groups.”
Bakker WM et al. Efficacy and safety of dapagliflozin in patients receiving dialysis: a post-hoc analysis of the DAPA-CKD trial. Clin Kidney J 2026 (PMC13339949) (2026)· DAPA-CKD dialysis post-hoc analysis, discussion Source
“Patients >18 years of age can be included when they belong to one of three groups: patients with advanced CKD, defined as an eGFR ≤25 ml/min/1.73 m2; peritoneal dialysis or haemodialysis patients (≥3 months after start of dialysis); or KTRs with an eGFR ≤45 ml/min/1.73 m2 (≥6 months after transplantation).”
Bakker WM, Heerspink HJL, et al. Rationale and design of the Renal Lifecycle trial assessing the effect of dapagliflozin on cardiorenal outcomes in severe chronic kidney disease. Nephrol Dial Transplant 2025;40:1746-55 (PMC12394133, Europe PMC full text) (2025)· Methods, inclusion criteria Source
“The DAPA-HD trial is the first randomized controlled trial to evaluate the cardiovascular effects of SGLT2i in patients with kidney failure receiving maintenance haemodialysis.”
Zelniker TA et al. Design, rationale and baseline characteristics of the DAPA-HD trial. ESC Heart Fail 2026 (PMC13189660) (2026)· Discussion Source
“The removal of dapagliflozin by hemodialysis has not been studied.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Section 10 Overdosage Source
“Evidence supporting the initiation of an SGLT2 inhibitor in patients with HF and eGFR <20 mL/min/1.73 m2 or those undergoing dialysis remains insufficient to support initiation in such patients.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 35, Section 6.2.1.2 Source
“Nonetheless, if treatment with an SGLT2 inhibitor is already established, it may be continued in patients whose eGFR declines <20 mL/min/1.73 m2, provided the therapy is well tolerated and KRT has not been initiated.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 35, Section 6.2.1.2 Source
“Practice Point 3.7.1: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20 ml/min per 1.73 m2, unless it is not tolerated or KRT is initiated.”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 44, Practice Point 3.7.1 Source
“Very few data are available evaluating use of SGLT2i for patients receiving dialysis, and the glucosuric actions of SGLT2i are likely insigniﬁcant with this degree of kidney failure. Therefore, it is reasonable to discontinue an SGLT2i prior to initiation of kidney replacement therapy.”
KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD (2022)· p. 49, Practice Point 1.3.6 rationale Source
“Type 1 diabetes mellitus (limitation to use) Lactation On dialysis Known hypersensitivity”
2023 ACC Expert Consensus Decision Pathway on Management of HFpEF (2023)· p. 18, Table 4 Source
“In the absence of robust data on the efficacy and safety of SGLT2i in patients with advanced CKD and ESKD it is wise at present to restrict their use in these populations.”
Minutolo R et al. SGLT2 inhibitors in hemodialysis or peritoneal dialysis patients: rationale and state-of-the art. Clin Kidney J 2026 (PMC12757745) (2026)· Conclusions Source

Kidney transplant

Evidence is limited and none is HF-specific. ESC CVD-CKD 2026 (Section 13): SGLT2i may be considered in kidney transplant recipients with T2D by extrapolation; one 44-patient RCT (empagliflozin, post-transplant diabetes) showed safety; other data are retrospective. RENAL LIFECYCLE includes a transplant stratum (eGFR <=45, >=6 months post-transplant), not yet reported. KDIGO 2024 figure: continue SGLT2i 'until dialysis or transplant'. Recommend: apply native-kidney eGFR rules with caution; flag infection risk under immunosuppression.

Trials: Dapagliflozin for post-transplant diabetes (KIR 2026)

“Dedicated trial data in kidney transplant recipients are limited.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 72 Source
“Lim et al. [10] showed in a retrospective study that KTRs with T2DM who had been treated with SGLT2 inhibitors had a better prognosis with respect to all-cause mortality, death-censored graft failure and doubling of serum creatinine compared with KTRs with T2DM not treated with SGLT2 inhibitors.”
Bakker WM, Heerspink HJL, et al. Rationale and design of the Renal Lifecycle trial assessing the effect of dapagliflozin on cardiorenal outcomes in severe chronic kidney disease. Nephrol Dial Transplant 2025;40:1746-55 (PMC12394133, Europe PMC full text) (2025)· Discussion Source
“Thus there is persistent uncertainty whether SGLT2 inhibitors will be effective in patients with severely impaired kidney function, on dialysis or living with a kidney transplant.”
Bakker WM, Heerspink HJL, et al. Rationale and design of the Renal Lifecycle trial assessing the effect of dapagliflozin on cardiorenal outcomes in severe chronic kidney disease. Nephrol Dial Transplant 2025;40:1746-55 (PMC12394133, Europe PMC full text) (2025)· Introduction Source
“SGLT2 inhibitors may be considered in kidney transplant recipients with either pre- or post-transplant diabetes to reduce cardiovascular risk”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 72, Recommendation Table 33 Source
“In a placebo-controlled trial with 44 patients with post-transplant diabetes, empagliflozin had a small effect on HbA1c but was generally safe and well tolerated.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 72, Section 13.2.2 Source
“Practice Point 1.3.7: SGLT2i have not been adequately studied in kidney transplant recipients, who may beneﬁt from SGLT2i treatment, but are immunosuppressed and potentially at increased risk for infections; therefore, the recommendation to use SGLT2i does not apply to kidney transplant recipients (see Recommendation 1.3.1).”
KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD (2022)· p. 22, Practice Point 1.3.7 Source
“A recent observational study reported a lower risk of major adverse cardiovascular events among KTR being treated with SGLT2i; however, no difference was found for the outcome of HF hospitalization.”
Ghimire A et al. Heart Failure in Kidney Transplant Recipients: Narrative Review of Risk Factors, Therapy, and Current Gaps. Cardiol Ther 2026 (PMC12988941) (2026)· SGLT2 inhibitors Source
“When initiating new treatment, consultation with the patient’s transplant team is advisable to ensure that there are no important considerations for the graft, and particularly relevant drug interactions.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 72, Section 13.2 Source

Albuminuria

For the HF indication, albuminuria does not change eligibility (KDIGO 2024: HF is an indication irrespective of albuminuria). Albuminuria thresholds (uACR >=200 mg/g) matter only for the CKD-without-diabetes, non-HF indication. Not a matrix modifier for this class.

“Note that a person with CKD and heart failure has a clear indication for the use of SGLT2i to reduce risk of cardiovascular death or hospitalization for heart failure irrespective of level of albuminuria (Figure 24).”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 103 Source
“An SGLT2 inhibitor is recommended in patients with CKD without diabetes with eGFR ≥20 mL/ min/1.73 m2 and uACR ≥20 mg/mmol (≥200 mg/g) to reduce the risk of kidney failure and cardiovascular events.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 31 (Recommendation Table 12, Class I A) Source

Monitoring

Check kidney function and volume status before starting (labels: correct volume depletion first, especially if eGFR <60, elderly, or on loop diuretics) and monitor renal function and signs of hypotension/volume depletion after initiation; consider reducing diuretic dose. No potassium monitoring requirement specific to SGLT2i. ESC CVD-CKD and KDIGO: no need to increase routine creatinine monitoring frequency solely because of SGLT2i. Trials typically checked labs ~2 weeks after starting. Educate on ketoacidosis and genital infections; sick-day rules (withhold during prolonged fasting, surgery >=3 days before, acute illness).

“Before initiating FARXIGA in patients with one or more of these characteristics, assess volume status and renal function. Monitor for signs and symptoms of hypotension, and renal function after initiating therapy.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Warnings and Precautions 5.2 Volume Depletion Source
“Check renal function when starting the therapy and monitor regularly.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 19 (Table S9, How to use) Source
“Although monitoring of potassium and creatinine is routine when initiating ACEI/ARBs and MRAs, on initiation of an SGLT2 inhibitor or GLP-1RA, we do not consider it necessary to routinely monitor creatinine/eGFR more frequently than for standard CKD monitoring, unless there is another reason (such as concern about volume depletion).”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 31 Source
“Practice Point 3.7.3: SGLT2i initiation or use does not necessitate alteration of frequency of CKD monitoring and the reversible decrease in eGFR on initiation is generally not an indication to discontinue therapy.”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 44 Source
“In the ACE-I/ARB/ARNI and SGLT2 inhibitor trials, laboratory assessment of creatinine, urea, eGFR and electrolytes was typically done after 14 days during drug titration and every 4 months thereafter.”
Mullens 2022 EJHF: Renal effects of GDMT in HF, HFA/ESC consensus statement (2022)· p. 14 Source

In-hospital initiation

Class I (ESC 2026): start an SGLT2i in hospital in patients with DHF after initial stabilisation (EMPULSE, DAPA ACT HF-TIMI 68, SOLOIST-WHF). ESC CVD-CKD: Class I early during admission in DHF with CKD and eGFR >20. Sotagliflozin label explicitly allows dosing once haemodynamically stable during hospitalisation. Continue SGLT2i already prescribed unless AKI with eGFR <15, ketoacidosis risk (fasting, surgery, critical illness) or volume depletion.

“In-hospital initiation of SGLT2-I is recommended in patients with DHF after initial stabilization to improve QoL and congestion symptoms and reduce the risk of HFH.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 12 Source
“Initiation of an SGLT2 inhibitor is recommended early during admission in patients with DHF and CKD with an eGFR >20 mL/min/1.73 m2 to improve signs and symptoms of congestion and reduce the risk of HF re-hospitalization.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 42 (Recommendation Table 17, Class I B1) Source
“For patients with decompensated heart failure, dosing may begin as soon as the patient is hemodynamically stable, including during hospitalization or urgent outpatient treatment or immediately upon discharge.”
INPEFA (sotagliflozin) PI, Lexicon (2026)· Section 2.1 Prior to Initiation of INPEFA Source
“Thus, early initiation of SGLT2-Is in DHF is recommended both as part of FMT (i.e. prognostic implications) and as a tool to enable optimal decongestion (Figure 15).”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 50 Source

Outpatient

Start at full 10 mg o.d. dose (no titration) in all symptomatic HF regardless of LVEF; can be started in clinic. Restart at the previous dose after an interruption of <14 days.

“Empagliflozin: starting (and target) dose 10 mg o.d. WHERE? In the community or in the hospital.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 19 (Table S9) Source
“It is recommended that patients with HFrEF and CKD maintain FMT, as several trials have shown beneficial effects on kidney endpoints as well as CV endpoints.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 35 Source

Where sources disagree

Initiation eGFR floor (HF indication)

“Initiation with FARXIGA is not recommended in patients with an eGFR less than 25 mL/min/1.73 m2.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Section 2.3 Recommended Dosage for Other Indications in Adults Source
“Use for glycemic control is not recommended in patients with an eGFR less than 30 mL/min/1.73 m2”
JARDIANCE (empagliflozin) PI, Boehringer Ingelheim (2026)· Section 2.1 Testing Prior to Initiation of JARDIANCE Source
“eGFR <20 mL/min/1.73 m2. Currently not approved for type 1 diabetes due to risk of ketoacidosis.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 19 (Table S9, Contraindications) Source
“Off-label initiation below this threshold is reasonable to consider given the safety of SGLT2 inhibition and since such patients are at the highest absolute risk of kidney failure.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 29 Source
“Kidney impairment: n For dapagliflozin, eGFR <25 mL/min/1.73 m 2 n For empagliflozin, eGFR <20 mL/min/1.73 m 2”
Kittleson MM, et al. Management of Heart Failure With Preserved Ejection Fraction: 2026 ACC Expert Consensus Decision Pathway. JACC 2026 (2026)· p. 15 (Table 5) Source
“(dapagliﬂozin), or 25 mL/min/1.73 m 2 (sotagliﬂozin), and if”
2024 ACC Expert Consensus Decision Pathway for Treatment of HFrEF (2024)· p. 18 Source
“20 mL/min/1.73 m 2 (empagliﬂozin), 30 mL/min/1.73 m 2”
2024 ACC Expert Consensus Decision Pathway for Treatment of HFrEF (2024)· p. 18 Source

Tool uses fda-dapagliflozin: Label > guideline: dapagliflozin initiation floor 25 (FDA). Empagliflozin label has no HF/CKD floor (only glycaemic <30), so use ESC 2026 Table S9 / ESC CVD-CKD floor of 20 (= trial enrolment floor). ESC CVD-CKD 'off-label initiation below 20 reasonable to consider' is written for CKD kidney-protection, not HF, and is not adopted (conservative). ACC 2024 ECDP lists dapagliflozin 30 (outdated, pre-label update; its own p. 15 text cites 25) and is superseded. ACC 2026 HFpEF Table 5 (dapagliflozin <25, empagliflozin <20) agrees with the proposal. The ACC 2024 quotes are column fragments of one sentence ('SGLT inhibitors may be initiated down to an eGFR of 20 (empagliflozin), 30 (dapagliflozin), or 25 (sotagliflozin), and if the eGFR drops below this value, discontinuation is not mandatory') because the PDF is two-column.

Continuation after starting maintenance dialysis

“Evidence supporting the initiation of an SGLT2 inhibitor in patients with HF and eGFR <20 mL/min/1.73 m2 or those undergoing dialysis remains insufficient to support initiation in such patients. Nonetheless, if treatment with an SGLT2 inhibitor is already established, it may be continued in patients whose eGFR declines <20 mL/min/1.73 m2, provided the therapy is well tolerated and KRT has not been initiated.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 35 Source
“Practice Point 3.7.1: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20 ml/min per 1.73 m2, unless it is not tolerated or KRT is initiated.”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 44 Source
“Once enrolled in the DAPA-CKD and DELIVER trials, adult patients were not required to discontinue therapy if eGFR fell below 25 mL/min/1.73 m2 or if dialysis was initiated.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Use in Specific Populations 8.6 Renal Impairment Source
“After starting therapy in these studies, patients were discontinued if eGFR fell below 15 mL/min/1.73 m2 or were initiated on chronic dialysis.”
INPEFA (sotagliflozin) PI, Lexicon (2026)· Use in Specific Populations 8.6 Renal Impairment Source
“Participants in the dapagliflozin group had significantly lower all-cause mortality (adjusted hazard ratio [aHR] 0.47, 95% CI: 0.23–0.98, Figure 1).”
Bakker WM et al. Efficacy and safety of dapagliflozin in patients receiving dialysis: a post-hoc analysis of the DAPA-CKD trial. Clin Kidney J 2026 (PMC13339949) (2026)· DAPA-CKD dialysis post-hoc analysis, results Source

Tool uses esc2026-ckd: FDA labels describe trial conduct only (no dosing instruction for dialysis), so the guideline position governs: ESC CVD-CKD 2026 and KDIGO 2024 both limit continuation to before KRT. Default 'not-recommended' for continuation on dialysis (conservative); revisit when RENAL LIFECYCLE reports.

Acceptable kidney-function change after initiation / on treatment

“An increase in serum creatinine of <50% above baseline, as long as eGFR remains >15 mL/min/1.73 m2, is considered acceptable.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 66 Source
“The therapies discussed in Section 5.5 are known to cause an acute dip in eGFR upon initiation, with clinicians typically tolerating <30% dips”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 31 Source
“Hemodynamic fluctuations in eGFR up to 30% can be seen and should not lead to discontinuation”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 10

Tool uses esc2026: ESC 2026 HF guideline is the primary framework: tolerate creatinine rise <50% (while eGFR >15) without interrupting; use the 30% eGFR decline (KDIGO HF conference / ESC CVD-CKD) as a prompt to look for other causes, not as a stop rule. Both numbers should be user-adjustable.

Routine kidney-function monitoring after SGLT2i initiation

“Before initiating FARXIGA in patients with one or more of these characteristics, assess volume status and renal function. Monitor for signs and symptoms of hypotension, and renal function after initiating therapy.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Warnings and Precautions 5.2 Volume Depletion Source
“Although monitoring of potassium and creatinine is routine when initiating ACEI/ARBs and MRAs, on initiation of an SGLT2 inhibitor or GLP-1RA, we do not consider it necessary to routinely monitor creatinine/eGFR more frequently than for standard CKD monitoring, unless there is another reason (such as concern about volume depletion).”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 31 Source

Tool uses fda-dapagliflozin: Label > guideline and HF patients usually receive loop diuretics (a label risk factor), so recommend a renal-function/volume check after initiation (e.g. 1-2 weeks, as in trials per Mullens 2022).

Sotagliflozin as an HF SGLT2i option

“INPEFA is indicated to reduce the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visit in adults with:”
INPEFA (sotagliflozin) PI, Lexicon (2026)· Section 1 Indications and Usage Source
“An SGLT2-I (dapagliflozin or empagliflozin) is recommended in patients with symptomatic HF independent of LVEF to reduce the risk of HFH or CV death.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 37 Source
“In the SOLOIST-WHF trial, initiation of sotagliflozin in hospital or within 3 days of discharge was safe and effective in patients with HF and diabetes.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 50 Source

Tool uses esc2026: ESC 2026-centric logic: dapagliflozin/empagliflozin are the FMT agents; show sotagliflozin as a label-supported alternative (ACC/AHA view) with its own renal rules (trial floor 25, stop <15/dialysis).

Open questions

G4 spans the 20/25 cut-offs: display as 'caution' with drug-specific thresholds (dapagliflozin >=25, empagliflozin >=20 to initiate), or split the cell?
Dialysis: keep conservative 'not-recommended' for continuation after KRT (ESC CVD-CKD/KDIGO) or follow label trial conduct + DAPA-CKD post hoc data and mark 'caution'? Revisit when RENAL LIFECYCLE / DAPA-HD report.
G5 not on dialysis: continuation set to 'caution'. ESC 2026 HF ties acceptable creatinine rise to eGFR >15 and suggests temporary discontinuation with AKI and eGFR <15; is 'caution' acceptable or should it be 'not-recommended'?
AKI: initiation set to 'caution' (defer until euvolaemic/stable) rather than 'not-recommended', because in congested DHF creatinine rises during decongestion and ESC recommends early in-hospital initiation. Confirm.
Include sotagliflozin (FDA HF label, not ESC FMT) as a selectable drug? Its 200->400 mg titration and trial-based renal stop rules differ from dapa/empa.
Empagliflozin: FDA label has no HF eGFR floor; proposal uses ESC 20. Owner to confirm this 'guideline over silent label' choice.
User-adjustable defaults proposed: initiation eGFR floor (25 dapa / 20 empa), SBP caution <95 mmHg (ESC Table S9), creatinine rise tolerance 50%, eGFR decline review trigger 30%.

SGLT2 inhibitors

FMT in HFrEF · Class IFMT in HFpEF · Class I

Open in the matrix

Removal by dialysis

What each drug's prescribing information says about removal by (haemo)dialysis. Where the label is silent, this page says so rather than inferring from protein binding.

DapagliflozinRemoval not studied
- “The removal of dapagliflozin by hemodialysis has not been studied.”
  FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· 10 OVERDOSAGE Source
EmpagliflozinRemoval not studied
- “Removal of empagliflozin by hemodialysis has not been studied.”
  JARDIANCE (empagliflozin) PI, Boehringer Ingelheim (2026)· 10 OVERDOSAGE Source

After starting: what a change in creatinine, eGFR or potassium means

“eGFR drops <20 mL/min/1.73 m2: seek other causes. Continuation of SGLT2-I is advised but may be after close monitoring.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 20, Table S9 Source
“Diuretic doses along with fluid intake should be balanced in order to avoid dehydration, symptomatic hypotension, and pre-renal kidney failure.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 20, Table S9 Source

“Hemodynamic fluctuations in eGFR up to 30% can be seen and should not lead to discontinuation”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 10
“If >30%, other causes of AKI should be evaluated”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 10
“An increase in serum creatinine of <50% above baseline, as long as eGFR remains >15 mL/min/1.73 m2, is considered acceptable.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 66, Section 10.3 Source
“Worsening kidney function alone is not an independent determinant of outcomes in patients with acute HF.”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 11

Drugs and doses

Drug	Brands	Start	Target	Kidney dosing
Dapagliflozin	Farxiga, Forxiga	10 mg o.d.	10 mg o.d.	No dose adjustment at any eGFR (always 10 mg o.d. for HF). FDA label: initiation not recommended at eGFR <25; if eGFR falls below 25 on treatment, may continue 10 mg o.d. Not studied for initiation <25 or in dialysis; DAPA-CKD/DELIVER did not require stopping if eGFR fell <25 or dialysis started. Glycaemic indication limited to eGFR >=45 (irrelevant for HF benefit).
Empagliflozin	Jardiance	10 mg o.d.	10 mg o.d.	No dose adjustment for HF (10 mg o.d.; 25 mg only for extra glycaemic control). The FDA label gives NO eGFR floor for the HF or CKD indications (only glycaemic use not recommended <30); HF/CKD trials enrolled eGFR >=20 and did not require stopping if eGFR fell <20 or dialysis started. ESC Table S9 / ESC CVD-CKD: do not initiate <20.
Sotagliflozin (SGLT1/2 inhibitor)	Inpefa	200 mg o.d.	400 mg o.d.	FDA-approved for HF (any LVEF) but NOT named in ESC 2026 FMT (ESC names dapagliflozin/empagliflozin only; sotagliflozin mentioned only for in-hospital initiation evidence from SOLOIST-WHF). Label has no explicit eGFR initiation floor; trials (SOLOIST-WHF, SCORED) did not enrol eGFR <25 or dialysis and stopped drug if eGFR fell <15 or chronic dialysis began. More volume-related AEs at eGFR <30. Exposure up to 170% higher in moderate renal impairment; label allows down-titration to 200 mg.

Status by kidney stage

Stage	Initiate	Continue
G1	Recommended Class I FMT in symptomatic HF regardless of LVEF; standard 10 mg o.d. dosing (dapagliflozin, empagliflozin).	Recommended Continue indefinitely at 10 mg o.d.
G2	Recommended Class I FMT (ESC 2026, AHA 2022 for HFrEF); no renal dose adjustment.	Recommended Continue indefinitely at 10 mg o.d.
G3a	Recommended Class I in HF with CKD (ESC CVD-CKD 2026, eGFR >=20); assess volume status first because eGFR <60 raises volume-depletion risk.	Recommended Continue; an early eGFR dip is expected and is not a reason to stop.
G3b	Recommended Class I; well represented in DAPA-HF (eGFR >=30), EMPEROR (>=20) and DAPA-CKD/EMPA-KIDNEY. Assess volume status before starting.	Recommended Continue; tolerate early eGFR dip.
G4	Use with caution Split stage: recommended at eGFR >=25 for dapagliflozin (label) and >=20 for empagliflozin (trial floor / ESC CVD-CKD Class I); initiation not recommended below 20 (ESC Table S9 lists eGFR <20 as a contraindication) and dapagliflozin label advises against starting <25. Use thresholds[] for the exact cut-off.	Recommended Continue if eGFR falls into G4 or below 20 (FDA dapagliflozin label; ESC CVD-CKD IIa; ESC Table S9; KDIGO PP 3.7.1).
G5	Not recommended Do not initiate at eGFR <15 (no trial data; ESC Table S9 eGFR <20 contraindication; ESC CVD-CKD: evidence insufficient <20).	Use with caution May continue if already established and tolerated and KRT not started (ESC CVD-CKD, KDIGO); dapagliflozin label permits continuation below 25 without a lower bound. ESC 2026 HF: temporary discontinuation may be needed with AKI and eGFR <15. Sotagliflozin was stopped at eGFR <15 in its trials.
dialysis	Not recommended No trial enrolled dialysis patients; ESC CVD-CKD states evidence is insufficient to support initiation. Dedicated RCTs (RENAL LIFECYCLE, DAPA-HD) are ongoing/unreported.	Not recommended Guidelines (ESC CVD-CKD 2026, KDIGO 2024) support continuation only until KRT is initiated. FDA dapagliflozin/empagliflozin labels note trial participants were not required to stop at dialysis initiation, and a post-hoc DAPA-CKD analysis suggests lower mortality, but this is hypothesis-generating. Conservative default: stop at maintenance dialysis; flag for owner review.
aki	Use with caution Defer initiation until volume depletion is corrected and kidney function is stable (labels). Exception: in congested DHF with eGFR >20, early in-hospital initiation is recommended and a creatinine rise during decongestion is not by itself AKI requiring deferral.	Use with caution Temporary hold may be needed in AKI (especially with eGFR <15 or volume depletion/acute illness); restart when stable. A transient eGFR dip after initiation is expected and should not prompt interruption.
transplant	Use with caution Very limited evidence: no HF outcome trial in kidney transplant recipients; small RCT (n=44, post-transplant diabetes) and observational data suggest safety. ESC CVD-CKD: may be considered in transplant recipients with T2D (extrapolated). Use the eGFR rules of the native-kidney stages plus infection vigilance.	Use with caution Continue with caution (genitourinary infection risk under immunosuppression); RENAL LIFECYCLE includes a transplant stratum (eGFR <=45) and is unreported.

Cutoffs recorded from the sources

egfr < 25 mL/min/1.73m2 → not-recommended (initiate; dapagliflozin)
“Initiation with FARXIGA is not recommended in patients with an eGFR less than 25 mL/min/1.73 m2.” — fda-dapagliflozin, Section 2.3 Recommended Dosage for Other Indications in Adults
egfr < 25 mL/min/1.73m2 → allowed (continue; dapagliflozin)
“If the eGFR falls below 25 mL/min/1.73 m2 while receiving treatment with FARXIGA, patients may continue FARXIGA 10 mg orally once daily to reduce the risk of eGFR decline, ESKD, CV death and hHF.” — fda-dapagliflozin, Section 2.3 Recommended Dosage for Other Indications in Adults
egfr < 20 mL/min/1.73m2 → not-recommended (initiate; dapagliflozin, empagliflozin)
“eGFR <20 mL/min/1.73 m2. Currently not approved for type 1 diabetes due to risk of ketoacidosis.” — esc2026-supp, p. 19 (Table S9, Contraindications)
egfr >= 20 mL/min/1.73m2 → recommended (initiate; dapagliflozin, empagliflozin)
“Treatment with an SGLT2 inhibitor is recommended in patients with HF and CKD with eGFR ≥20 mL/min/1.73 m2 irrespective of LVEF, to reduce the risk of (repeated) HF hospitalization and cardiovascular death.” — esc2026-ckd, p. 39 (Recommendation Table 15, Class I A)
egfr < 20 mL/min/1.73m2 → recommended (continue; dapagliflozin, empagliflozin)
“Continuation of a SGLT2 inhibitor should be considered in patients with HF and CKD in whom the eGFR progresses to <20 mL/min/ 1.73 m2” — esc2026-ckd, p. 44 (Recommendation Table 18, Class IIa C)
egfr < 15 mL/min/1.73m2 → caution (hold; dapagliflozin, empagliflozin, sotagliflozin)
“However, temporary discontinuation of MRAs/ARNIs/ACE-Is/ARBs and SGLT2-Is may be needed in cases with acute kidney injury and eGFR <15 mL/min/1.73 m2.” — esc2026, p. 35
creatinine_rise_pct < 50 % above baseline → allowed (continue; dapagliflozin, empagliflozin, sotagliflozin)
“An increase in serum creatinine of <50% above baseline, as long as eGFR remains >15 mL/min/1.73 m2, is considered acceptable.” — esc2026, p. 66
other > 30 % eGFR decline from baseline → caution (continue; dapagliflozin, empagliflozin, sotagliflozin)
“Hemodynamic fluctuations in eGFR up to 30% can be seen and should not lead to discontinuation” — kdigo2026-hf, p. 10
egfr < 45 mL/min/1.73m2 → not-recommended (initiate; dapagliflozin)
“FARXIGA is not recommended for use to improve glycemic control in patients with type 2 diabetes mellitus with an eGFR less than 45 mL/min/1.73 m2.” — fda-dapagliflozin, Section 2.2 Recommended Dosage for Glycemic Control
egfr < 30 mL/min/1.73m2 → not-recommended (initiate; empagliflozin)
“Use for glycemic control is not recommended in patients with an eGFR less than 30 mL/min/1.73 m2” — fda-empagliflozin, Section 2.1 Testing Prior to Initiation of JARDIANCE
egfr < 25 mL/min/1.73m2 → caution (initiate; sotagliflozin)
“Efficacy and safety studies with INPEFA did not enroll patients with an eGFR less than 25 mL/min/1.73 m2 or on dialysis.” — fda-sotagliflozin, Use in Specific Populations 8.6 Renal Impairment
egfr < 15 mL/min/1.73m2 → not-recommended (continue; sotagliflozin)
“After starting therapy in these studies, patients were discontinued if eGFR fell below 15 mL/min/1.73 m2 or were initiated on chronic dialysis.” — fda-sotagliflozin, Use in Specific Populations 8.6 Renal Impairment
sbp < 95 mmHg → caution (initiate; dapagliflozin, empagliflozin)
“Symptoms of hypotension and a systolic blood pressure <95 mmHg.” — esc2026-supp, p. 19 (Table S9, Cautions/seek specialist advice)
sbp < 100 mmHg → caution (initiate; sotagliflozin)
“Patients were randomized to treatment if they met the following criteria for clinical stability: no need for oxygen therapy, a systolic blood pressure of at least 100 mmHg, no need for intravenous inotropic or vasodilator therapy (excluding nitrates) and transitioned from intravenous to oral diuretic therapy.” — fda-sotagliflozin, Clinical Studies 14.1 SOLOIST Study
other >= 3 days before surgery or prolonged fasting → caution (hold; dapagliflozin, empagliflozin, sotagliflozin)
“Withhold FARXIGA for at least 3 days, if possible, prior to surgery or procedures associated with prolonged fasting. Resume FARXIGA when the patient is clinically stable and has resumed oral intake” — fda-dapagliflozin, Section 2.4 Temporary Interruption for Surgery
other < 14 days since temporary discontinuation (restart at previous dose) → allowed (initiate; dapagliflozin, empagliflozin)
“If SGLT2-I has been temporarily discontinued for less than 14 days, it should, in most cases, be safe to initiate directly at the previously tolerated doses in stable patients.” — esc2026-supp, p. 19 (Table S9)

Trial evidence (informational)

DAPA-HF · HFrEF (LVEF <=40%), NYHA II-IV, eGFR >=30
CV death, HF hospitalisation or urgent HF visit: HR 0.74 (95% CI 0.65-0.85)
“386(11.6) | 386(11.6) 502(15.6) | 502(15.6) 0.74(0.65, 0.85) | 0.74(0.65, 0.85)” — fda-dapagliflozin, Clinical Studies 14.5, Table 17 (DAPA-HF column)
EMPEROR-Reduced · HFrEF (LVEF <=40%), NYHA II-IV, eGFR >=20
CV death or HF hospitalisation: HR 0.75 (95% CI 0.65-0.86)
“CV death or HHFa | 462 (24.7%) | 361 (19.4%) | 0.75 (0.65, 0.86) | <0.0001 |” — fda-empagliflozin, Clinical Studies 14.4, Table 16
DAPA-HF + EMPEROR-Reduced · HFrEF
CV death or HF hospitalisation: ~25% relative reduction
“In the DAPA-HF and EMPEROR-Reduced trials, SGLT2i compared with placebo reduced the composite of cardiovascular death or HF hospitalization by approximately 25% (1,2,9).” — aha2022, p. 45
EMPEROR-Preserved · HF with LVEF >40%, eGFR >=20
CV death or HF hospitalisation: HR 0.79 (95% CI 0.69-0.90)
“At a median follow-up of 26.2 months, empagliflozin reduced the primary endpoint (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.69–0.90; P < .001).” — esc2023-update, p. 6
DELIVER · HF with LVEF >40%, eGFR >=25
CV death or worsening HF: HR 0.82 (95% CI 0.73-0.92)
“Dapagliflozin reduced the primary endpoint of CV death or worsening HF (HF hospitalization or urgent HF visit) (HR 0.82, 95% CI 0.73– 0.92; P < .001).” — esc2023-update, p. 6
SOLOIST-WHF · T2D with recent worsening HF (any LVEF), started in hospital or early after discharge
Total CV death, HF hospitalisation and urgent HF visits: HR 0.67 (95% CI 0.53-0.85)
“INPEFA was superior to placebo in reducing the risk of the primary composite endpoint (Hazard Ratio [HR] 0.67 [95% confidence interval (CI) 0.53, 0.85]; p = 0.001).” — fda-sotagliflozin, Clinical Studies 14.1 SOLOIST Study
EMPULSE · Hospitalised acute HF after stabilisation
Hierarchical clinical benefit at 90 days: Significantly higher chance of clinical benefit
“The EMPULSE trial demonstrated that in-hospital initiation of 10 mg empagliflozin resulted in significantly higher chances of clinical benefit, at 90 days” — esc2026, p. 50
Cross-trial lifetime analysis (DELIVER, FINEARTS-HF, PARAGON-HF) · HFmrEF/HFpEF
CV death or first worsening HF event; event-free years: SGLT2i + finerenone HR 0.69 (0.59-0.81); +3.6 event-free years at age 65
“With long-term use, combined SGLT2i and nsMRA therapies in a 65-year-old patient with HFmrEF/HFpEF, or combined SGLT2i, nsMRA and ARNI therapies in a 65-year-old patient with an LVEF <60%, were projected to afford 3.6 (2.0–5.2) or 4.9 (2.5–7.3) additional years free from cardiovascular death or a heart failure event, respectively.” — vaduganathan2026, p. 1
DAPA-CKD (dialysis-initiators, post hoc) · CKD patients who started dialysis during DAPA-CKD (n=167)
All-cause mortality after dialysis initiation: aHR 0.47 (95% CI 0.23-0.98); non-randomised, hypothesis-generating
“Participants in the dapagliflozin group had significantly lower all-cause mortality (adjusted hazard ratio [aHR] 0.47, 95% CI: 0.23–0.98, Figure 1).” — bakker2026, DAPA-CKD dialysis post-hoc analysis, results

Acute kidney injury

“In addition to reducing kidney failure and cardiovascular risk, SGLT2 inhibitors reduce the risk of reported AKI by around one-quarter overall in the studied populations.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 29 Source
“Thus, a transient decrease in kidney function after the initiation of ACE-Is/ARNIs/ARBs and MRAs or SGLT2-Is should not prompt their interruption.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 66 Source
“Changes that do not fit this pattern should prompt further evaluation to exclude the possibility of acute kidney injury.”
INPEFA (sotagliflozin) PI, Lexicon (2026)· Adverse Reactions 6.1, Increase in Serum Creatinine and Decrease in eGFR Source
“None of the large trials demonstrated an increased risk of AKI in people treated with SGLT2i (Figure 22)”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 102 Source
“Diuretic doses along with fluid intake should be balanced in order to avoid dehydration, symptomatic hypotension, and pre-renal kidney failure.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 20 (Table S9, Problem solving) Source

Dialysis

“The effects of SGLT2 inhibition at lower eGFR than studied in the reported trials and in patients requiring KRT are being assessed in the ongoing RENAL LIFECYCLE trial (NCT05374291).”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 29 Source
“Once enrolled, adult patients in the EMPA-REG OUTCOME, EMPEROR-Reduced, EMPEROR-Preserved, and EMPA-KIDNEY trials were not required to discontinue therapy for worsening of eGFR to less than 20 mL/min/1.73 m2 or initiation of dialysis”
JARDIANCE (empagliflozin) PI, Boehringer Ingelheim (2026)· Use in Specific Populations 8.6 Renal Impairment Source
“SGLT2i continue until dialysis or transplant”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 91 (Figure) Source
“Out of the total study population of the DAPA-CKD trial (n = 4304), 167 participants initiated dialysis during the study.”
Bakker WM et al. Efficacy and safety of dapagliflozin in patients receiving dialysis: a post-hoc analysis of the DAPA-CKD trial. Clin Kidney J 2026 (PMC13339949) (2026)· DAPA-CKD dialysis post-hoc analysis, results Source
“Of course, these data should be interpreted with caution as the number of patients included in this analysis was low, and due to the non-randomized post-hoc design characteristics of subjects at start of dialysis differed between both study groups.”
Bakker WM et al. Efficacy and safety of dapagliflozin in patients receiving dialysis: a post-hoc analysis of the DAPA-CKD trial. Clin Kidney J 2026 (PMC13339949) (2026)· DAPA-CKD dialysis post-hoc analysis, discussion Source
“Patients >18 years of age can be included when they belong to one of three groups: patients with advanced CKD, defined as an eGFR ≤25 ml/min/1.73 m2; peritoneal dialysis or haemodialysis patients (≥3 months after start of dialysis); or KTRs with an eGFR ≤45 ml/min/1.73 m2 (≥6 months after transplantation).”
Bakker WM, Heerspink HJL, et al. Rationale and design of the Renal Lifecycle trial assessing the effect of dapagliflozin on cardiorenal outcomes in severe chronic kidney disease. Nephrol Dial Transplant 2025;40:1746-55 (PMC12394133, Europe PMC full text) (2025)· Methods, inclusion criteria Source
“The DAPA-HD trial is the first randomized controlled trial to evaluate the cardiovascular effects of SGLT2i in patients with kidney failure receiving maintenance haemodialysis.”
Zelniker TA et al. Design, rationale and baseline characteristics of the DAPA-HD trial. ESC Heart Fail 2026 (PMC13189660) (2026)· Discussion Source
“The removal of dapagliflozin by hemodialysis has not been studied.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Section 10 Overdosage Source
“Evidence supporting the initiation of an SGLT2 inhibitor in patients with HF and eGFR <20 mL/min/1.73 m2 or those undergoing dialysis remains insufficient to support initiation in such patients.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 35, Section 6.2.1.2 Source
“Nonetheless, if treatment with an SGLT2 inhibitor is already established, it may be continued in patients whose eGFR declines <20 mL/min/1.73 m2, provided the therapy is well tolerated and KRT has not been initiated.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 35, Section 6.2.1.2 Source
“Practice Point 3.7.1: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20 ml/min per 1.73 m2, unless it is not tolerated or KRT is initiated.”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 44, Practice Point 3.7.1 Source
“Very few data are available evaluating use of SGLT2i for patients receiving dialysis, and the glucosuric actions of SGLT2i are likely insigniﬁcant with this degree of kidney failure. Therefore, it is reasonable to discontinue an SGLT2i prior to initiation of kidney replacement therapy.”
KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD (2022)· p. 49, Practice Point 1.3.6 rationale Source
“Type 1 diabetes mellitus (limitation to use) Lactation On dialysis Known hypersensitivity”
2023 ACC Expert Consensus Decision Pathway on Management of HFpEF (2023)· p. 18, Table 4 Source
“In the absence of robust data on the efficacy and safety of SGLT2i in patients with advanced CKD and ESKD it is wise at present to restrict their use in these populations.”
Minutolo R et al. SGLT2 inhibitors in hemodialysis or peritoneal dialysis patients: rationale and state-of-the art. Clin Kidney J 2026 (PMC12757745) (2026)· Conclusions Source

Kidney transplant

Trials: Dapagliflozin for post-transplant diabetes (KIR 2026)

“Dedicated trial data in kidney transplant recipients are limited.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 72 Source
“Lim et al. [10] showed in a retrospective study that KTRs with T2DM who had been treated with SGLT2 inhibitors had a better prognosis with respect to all-cause mortality, death-censored graft failure and doubling of serum creatinine compared with KTRs with T2DM not treated with SGLT2 inhibitors.”
Bakker WM, Heerspink HJL, et al. Rationale and design of the Renal Lifecycle trial assessing the effect of dapagliflozin on cardiorenal outcomes in severe chronic kidney disease. Nephrol Dial Transplant 2025;40:1746-55 (PMC12394133, Europe PMC full text) (2025)· Discussion Source
“Thus there is persistent uncertainty whether SGLT2 inhibitors will be effective in patients with severely impaired kidney function, on dialysis or living with a kidney transplant.”
Bakker WM, Heerspink HJL, et al. Rationale and design of the Renal Lifecycle trial assessing the effect of dapagliflozin on cardiorenal outcomes in severe chronic kidney disease. Nephrol Dial Transplant 2025;40:1746-55 (PMC12394133, Europe PMC full text) (2025)· Introduction Source
“SGLT2 inhibitors may be considered in kidney transplant recipients with either pre- or post-transplant diabetes to reduce cardiovascular risk”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 72, Recommendation Table 33 Source
“In a placebo-controlled trial with 44 patients with post-transplant diabetes, empagliflozin had a small effect on HbA1c but was generally safe and well tolerated.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 72, Section 13.2.2 Source
“Practice Point 1.3.7: SGLT2i have not been adequately studied in kidney transplant recipients, who may beneﬁt from SGLT2i treatment, but are immunosuppressed and potentially at increased risk for infections; therefore, the recommendation to use SGLT2i does not apply to kidney transplant recipients (see Recommendation 1.3.1).”
KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD (2022)· p. 22, Practice Point 1.3.7 Source
“A recent observational study reported a lower risk of major adverse cardiovascular events among KTR being treated with SGLT2i; however, no difference was found for the outcome of HF hospitalization.”
Ghimire A et al. Heart Failure in Kidney Transplant Recipients: Narrative Review of Risk Factors, Therapy, and Current Gaps. Cardiol Ther 2026 (PMC12988941) (2026)· SGLT2 inhibitors Source
“When initiating new treatment, consultation with the patient’s transplant team is advisable to ensure that there are no important considerations for the graft, and particularly relevant drug interactions.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 72, Section 13.2 Source

Albuminuria

“Note that a person with CKD and heart failure has a clear indication for the use of SGLT2i to reduce risk of cardiovascular death or hospitalization for heart failure irrespective of level of albuminuria (Figure 24).”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 103 Source
“An SGLT2 inhibitor is recommended in patients with CKD without diabetes with eGFR ≥20 mL/ min/1.73 m2 and uACR ≥20 mg/mmol (≥200 mg/g) to reduce the risk of kidney failure and cardiovascular events.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 31 (Recommendation Table 12, Class I A) Source

Monitoring

“Before initiating FARXIGA in patients with one or more of these characteristics, assess volume status and renal function. Monitor for signs and symptoms of hypotension, and renal function after initiating therapy.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Warnings and Precautions 5.2 Volume Depletion Source
“Check renal function when starting the therapy and monitor regularly.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 19 (Table S9, How to use) Source
“Although monitoring of potassium and creatinine is routine when initiating ACEI/ARBs and MRAs, on initiation of an SGLT2 inhibitor or GLP-1RA, we do not consider it necessary to routinely monitor creatinine/eGFR more frequently than for standard CKD monitoring, unless there is another reason (such as concern about volume depletion).”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 31 Source
“Practice Point 3.7.3: SGLT2i initiation or use does not necessitate alteration of frequency of CKD monitoring and the reversible decrease in eGFR on initiation is generally not an indication to discontinue therapy.”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 44 Source
“In the ACE-I/ARB/ARNI and SGLT2 inhibitor trials, laboratory assessment of creatinine, urea, eGFR and electrolytes was typically done after 14 days during drug titration and every 4 months thereafter.”
Mullens 2022 EJHF: Renal effects of GDMT in HF, HFA/ESC consensus statement (2022)· p. 14 Source

In-hospital initiation

“In-hospital initiation of SGLT2-I is recommended in patients with DHF after initial stabilization to improve QoL and congestion symptoms and reduce the risk of HFH.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 12 Source
“Initiation of an SGLT2 inhibitor is recommended early during admission in patients with DHF and CKD with an eGFR >20 mL/min/1.73 m2 to improve signs and symptoms of congestion and reduce the risk of HF re-hospitalization.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 42 (Recommendation Table 17, Class I B1) Source
“For patients with decompensated heart failure, dosing may begin as soon as the patient is hemodynamically stable, including during hospitalization or urgent outpatient treatment or immediately upon discharge.”
INPEFA (sotagliflozin) PI, Lexicon (2026)· Section 2.1 Prior to Initiation of INPEFA Source
“Thus, early initiation of SGLT2-Is in DHF is recommended both as part of FMT (i.e. prognostic implications) and as a tool to enable optimal decongestion (Figure 15).”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 50 Source

Outpatient

Start at full 10 mg o.d. dose (no titration) in all symptomatic HF regardless of LVEF; can be started in clinic. Restart at the previous dose after an interruption of <14 days.

“Empagliflozin: starting (and target) dose 10 mg o.d. WHERE? In the community or in the hospital.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 19 (Table S9) Source
“It is recommended that patients with HFrEF and CKD maintain FMT, as several trials have shown beneficial effects on kidney endpoints as well as CV endpoints.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 35 Source

Where sources disagree

Initiation eGFR floor (HF indication)

“Initiation with FARXIGA is not recommended in patients with an eGFR less than 25 mL/min/1.73 m2.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Section 2.3 Recommended Dosage for Other Indications in Adults Source
“Use for glycemic control is not recommended in patients with an eGFR less than 30 mL/min/1.73 m2”
JARDIANCE (empagliflozin) PI, Boehringer Ingelheim (2026)· Section 2.1 Testing Prior to Initiation of JARDIANCE Source
“eGFR <20 mL/min/1.73 m2. Currently not approved for type 1 diabetes due to risk of ketoacidosis.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 19 (Table S9, Contraindications) Source
“Off-label initiation below this threshold is reasonable to consider given the safety of SGLT2 inhibition and since such patients are at the highest absolute risk of kidney failure.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 29 Source
“Kidney impairment: n For dapagliflozin, eGFR <25 mL/min/1.73 m 2 n For empagliflozin, eGFR <20 mL/min/1.73 m 2”
Kittleson MM, et al. Management of Heart Failure With Preserved Ejection Fraction: 2026 ACC Expert Consensus Decision Pathway. JACC 2026 (2026)· p. 15 (Table 5) Source
“(dapagliﬂozin), or 25 mL/min/1.73 m 2 (sotagliﬂozin), and if”
2024 ACC Expert Consensus Decision Pathway for Treatment of HFrEF (2024)· p. 18 Source
“20 mL/min/1.73 m 2 (empagliﬂozin), 30 mL/min/1.73 m 2”
2024 ACC Expert Consensus Decision Pathway for Treatment of HFrEF (2024)· p. 18 Source

Continuation after starting maintenance dialysis

“Evidence supporting the initiation of an SGLT2 inhibitor in patients with HF and eGFR <20 mL/min/1.73 m2 or those undergoing dialysis remains insufficient to support initiation in such patients. Nonetheless, if treatment with an SGLT2 inhibitor is already established, it may be continued in patients whose eGFR declines <20 mL/min/1.73 m2, provided the therapy is well tolerated and KRT has not been initiated.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 35 Source
“Practice Point 3.7.1: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20 ml/min per 1.73 m2, unless it is not tolerated or KRT is initiated.”
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD (2024)· p. 44 Source
“Once enrolled in the DAPA-CKD and DELIVER trials, adult patients were not required to discontinue therapy if eGFR fell below 25 mL/min/1.73 m2 or if dialysis was initiated.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Use in Specific Populations 8.6 Renal Impairment Source
“After starting therapy in these studies, patients were discontinued if eGFR fell below 15 mL/min/1.73 m2 or were initiated on chronic dialysis.”
INPEFA (sotagliflozin) PI, Lexicon (2026)· Use in Specific Populations 8.6 Renal Impairment Source
“Participants in the dapagliflozin group had significantly lower all-cause mortality (adjusted hazard ratio [aHR] 0.47, 95% CI: 0.23–0.98, Figure 1).”
Bakker WM et al. Efficacy and safety of dapagliflozin in patients receiving dialysis: a post-hoc analysis of the DAPA-CKD trial. Clin Kidney J 2026 (PMC13339949) (2026)· DAPA-CKD dialysis post-hoc analysis, results Source

Acceptable kidney-function change after initiation / on treatment

“An increase in serum creatinine of <50% above baseline, as long as eGFR remains >15 mL/min/1.73 m2, is considered acceptable.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 66 Source
“The therapies discussed in Section 5.5 are known to cause an acute dip in eGFR upon initiation, with clinicians typically tolerating <30% dips”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 31 Source
“Hemodynamic fluctuations in eGFR up to 30% can be seen and should not lead to discontinuation”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 10

Routine kidney-function monitoring after SGLT2i initiation

“Before initiating FARXIGA in patients with one or more of these characteristics, assess volume status and renal function. Monitor for signs and symptoms of hypotension, and renal function after initiating therapy.”
FARXIGA (dapagliflozin) tablets, prescribing information, AstraZeneca Pharmaceuticals LP (2026)· Warnings and Precautions 5.2 Volume Depletion Source
“Although monitoring of potassium and creatinine is routine when initiating ACEI/ARBs and MRAs, on initiation of an SGLT2 inhibitor or GLP-1RA, we do not consider it necessary to routinely monitor creatinine/eGFR more frequently than for standard CKD monitoring, unless there is another reason (such as concern about volume depletion).”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 31 Source

Sotagliflozin as an HF SGLT2i option

“INPEFA is indicated to reduce the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visit in adults with:”
INPEFA (sotagliflozin) PI, Lexicon (2026)· Section 1 Indications and Usage Source
“An SGLT2-I (dapagliflozin or empagliflozin) is recommended in patients with symptomatic HF independent of LVEF to reduce the risk of HFH or CV death.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 37 Source
“In the SOLOIST-WHF trial, initiation of sotagliflozin in hospital or within 3 days of discharge was safe and effective in patients with HF and diabetes.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 50 Source

Open questions

G4 spans the 20/25 cut-offs: display as 'caution' with drug-specific thresholds (dapagliflozin >=25, empagliflozin >=20 to initiate), or split the cell?
Dialysis: keep conservative 'not-recommended' for continuation after KRT (ESC CVD-CKD/KDIGO) or follow label trial conduct + DAPA-CKD post hoc data and mark 'caution'? Revisit when RENAL LIFECYCLE / DAPA-HD report.
G5 not on dialysis: continuation set to 'caution'. ESC 2026 HF ties acceptable creatinine rise to eGFR >15 and suggests temporary discontinuation with AKI and eGFR <15; is 'caution' acceptable or should it be 'not-recommended'?
AKI: initiation set to 'caution' (defer until euvolaemic/stable) rather than 'not-recommended', because in congested DHF creatinine rises during decongestion and ESC recommends early in-hospital initiation. Confirm.
Include sotagliflozin (FDA HF label, not ESC FMT) as a selectable drug? Its 200->400 mg titration and trial-based renal stop rules differ from dapa/empa.
Empagliflozin: FDA label has no HF eGFR floor; proposal uses ESC 20. Owner to confirm this 'guideline over silent label' choice.
User-adjustable defaults proposed: initiation eGFR floor (25 dapa / 20 empa), SBP caution <95 mmHg (ESC Table S9), creatinine rise tolerance 50%, eGFR decline review trigger 30%.