The perioperative management of SGLT2 inhibitors has been a source of ongoing debate since the emergence of euglycemic DKA as a recognized complication. Current guidelines from the American Diabetes Association recommend holding SGLT2 inhibitors 3–4 days before elective surgery, a recommendation that has been broadly extrapolated to all hospitalizations.

However, a new retrospective cohort study published in the *Journal of the American Society of Nephrology* challenges the assumption that SGLT2 inhibitor use increases AKI risk in hospitalized patients.

Study Design

Investigators analyzed 42,318 patients hospitalized at 14 academic medical centers between 2022 and 2025. Patients were stratified by SGLT2 inhibitor use in the 30 days prior to admission. The primary outcome was AKI stage 1 or higher by KDIGO criteria within 72 hours of admission.

Key Findings

After multivariable adjustment, SGLT2 inhibitor use was associated with a 23% reduction in AKI risk (adjusted OR 0.77, 95% CI 0.68–0.87, p<0.001). This protective association was most pronounced in patients with baseline eGFR 30–60 mL/min/1.73m² and in those admitted for cardiac or infectious indications.

The proposed mechanism involves SGLT2 inhibitor-mediated reduction in tubuloglomerular feedback, leading to afferent arteriolar dilation and improved medullary oxygenation under conditions of hemodynamic stress.

Limitations

As a retrospective study, residual confounding cannot be excluded. Patients who continued SGLT2 inhibitors may represent a healthier, more closely monitored population. Prospective randomized data are needed before practice change can be definitively recommended.

Clinical Implications

These findings add to a growing body of evidence suggesting that the renoprotective effects of SGLT2 inhibitors may extend to the acute setting. Nephrologists should be involved in perioperative medication reconciliation decisions, particularly for patients with CKD where the risk-benefit calculation is most nuanced.