SGLT2i Expected Ketonuria Non-Diabetic Reassurance — ESENeph MCQ

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EasyChronic Kidney DiseaseSGLT2i Expected Ketonuria Non-Diabetic ReassuranceESENeph

A 70-year-old woman with CKD G4 (eGFR 20 mL/min/1.73m2) is started on dapagliflozin for CKD progression. She is not diabetic. She notices trace ketones on urine dipstick during a routine check. She feels well. What is the appropriate action?

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Correct answer: D — Continue with ketone safety-netting while well

SGLT2 inhibitors cause glycosuria, which shifts energy metabolism towards fatty acid oxidation, producing mild ketonaemia and ketonuria as a normal pharmacological consequence. In non-diabetic CKD patients (e.g., DAPA-CKD, EMPA-KIDNEY populations), trace ketonuria is expected, benign, and does NOT indicate DKA risk. DKA risk is specific to type 1 diabetes and type 2 diabetes with relative insulin deficiency. The patient is well with no symptoms of DKA (no nausea, vomiting, abdominal pain, Kussmaul breathing, or metabolic acidosis). No action is required beyond routine monitoring. Understanding this expected finding prevents unnecessary SGLT2i discontinuation and loss of renoprotective benefit.

Reference: KDIGO 2024 – CKD Guideline; EMPA-KIDNEY Collaborative 2023: https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf