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SGLT2i eGFR Dip — EECC MCQ

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ModerateHeart FailureSGLT2i eGFR DipEECC

A 65-year-old man with HFrEF (LVEF 22%) and CKD stage 3b (eGFR 32 mL/min) is started on dapagliflozin 10 mg. His eGFR drops from 32 to 27 mL/min in the first 2 weeks. Should dapagliflozin be stopped?

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Correct answer: A — No — an initial eGFR dip of up to 5-10 mL/min is expected (haemodynamic effect from afferent arteriolar vasoconstriction) and is associated with long-term nephroprotection; dapagliflozin should be continued

SGLT2 inhibitors cause an initial dip in eGFR (typically 2-5 mL/min, sometimes up to 10) within the first weeks of therapy, mediated by afferent arteriolar vasoconstriction reducing intraglomerular pressure (similar to the mechanism of RAAS inhibitor-induced eGFR dip). This initial dip is NOT a sign of nephrotoxicity — it is a protective haemodynamic effect that reduces hyperfiltration damage. Long-term data from DAPA-CKD and EMPA-KIDNEY show that SGLT2 inhibitors slow eGFR decline over years. The ESC HF and KDIGO guidelines recommend continuing SGLT2 inhibitors through this initial dip. They can be initiated down to eGFR 20 mL/min (per DAPA-CKD) and continued until dialysis or transplant.

Reference: ESC (2023): HF Guidelines; DAPA-CKD Trial; KDIGO 2024 Guidelines