Do you recommend continuing SGLT2 inhibitors in patients with diabetic kidney disease and congestive heart failure who have been taking the medication for several years and later develop end stage kidney disease?

The very premise on which SGLT2i is supposed to work does not exist, if the patient does not have meaningful GFR; in fact most would not use/start SGLT2i once eGFR is <20-25 range. Studies have excluded patients with advanced CKD and any benefit with low GFR seems very doubtful.

• Zinman et al., PMID...

I would continue them. There is practically no evidence of harm and if anything, the impact of these drugs is greater at lower GFR. What is the mechanistic difference between a GFR of 31 and 25, or 30 and 19? Furthermore, ultimately we do not completely understand the MOA of this class of drugs.

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