In which patients with non-proteinuric chronic kidney disease would you initiate a SGLT2i?

I agree with Dr. @Dr. First Last. I do not use SGLT2i in non-proteinuric diseases for kidney protection indication. EMPA-Kidney study also did not show benefit for UACR <30 (HR 1.01, 0.66-1.55) among >1200 participants with UACR <30 in the trial. While the secondary analysis looking at mean annual change in eGFR showed possible benefit for empagliflozin in individuals with UACR <30, I would like to see benefit in hard outcomes and replication of this result before using SGLT2i for non-albuminuric CKD. I do recommend the use in non-proteinuric patients if they have other indications - uncontrolled diabetes, obesity or heart failure.

At this point, the answer is none, since I wouldn't have decrease in proteinuria as a marker to assess the efficacy of the SGLT2i. Also, since the use of SGLT2i's in non-proteinuric CKD is off-label, I doubt any prescription drug plan would approve payment for these agents in such a setting (other than in patients with diabetic nephropathy where the indication would be control of diabetes and not renal protection).

At this time, I don't. I think we need more data before starting SGLT2i for kidney disease in non-proteinuric patients. Of course, they may be on one because of heart disease or diabetes by other physician. In that case, I clearly would not stop them.