Many chronic kidney disease (CKD) patients also face high blood pressure, diabetes, and heart disease. This can put CKD patients at higher risk for adverse cardiovascular (CV) events, such as heart attacks and strokes. In an effort to drastically reduce the risk of CV events, CKD progression, and cardiovascular deaths, scientists are looking to two new medications: sodium-glucose transport protein 2 inhibitors (SGLT2i), and mineralocorticoid receptor antagonists (MRAs). Learn more about them here.*

What is an SGLT2i?

While the mechanism is not completely understood, SGLT2i is a new medication that improves CV outcomes by hemodynamic effects. Hemodynamics is a branch of physiology related to blood flow and circulation, and also refers to measurements of cardiovascular function.

Providers have been hesitant to prescribe this medication due to its potential side effects. One of their top concerns for CKD patients is the risk for increased kidney function decline, however multiple studies report that there is no long-term decline in eGFR after an initial dip. 

After starting SGLTI2i, certain laboratory parameters will need to be monitored by your clinician for two to four weeks after initiating the medication. These include:

• Fluid volume depletion, 
• Low blood pressure, and 
• Ketonemia (unusual increase in ketones in your blood). Ketones are substances produced by your liver from fatty acids. Your body uses them as fuel when there is insufficient glucose.  

What is a non-steroidal MRA?

For patients with diabetic kidney disease (DKD), a non-steroidal MRA is a promising therapeutic option to help slow CKD progression and reduce the risk of adverse CV outcomes. The medication acts as a protector by blocking the activation of certain cells, such as inflammatory cells.

Moreover, non-steroidal MRAs, such as finerenone, carry a lower risk of hyperkalemia (high potassium blood levels) and albuminuria (protein in the urine) in DKD patients. 

What are the potential obstacles?

As novel medications, SGLT2i and non-steroidal MRAs do face obstacles with insurance companies. Insurance coverage denials and high out-of-pocket costs hinder the use of these medications. 

Since these drugs are being deemed safe and effective in the medical community, kidney health advocates are working to make the medications more widely available. With the current Advancing American Kidney Health initiative and alternative payment models, the kidney community is pushing to explore cost-sharing or cost coverage options for SLGTi and non-steroidal MRAs. 

*Gupta, N. (2022, February 16). New therapeutic agents may be the ‘holy grail’ for cardiovascular risk management in CKD. Healio. https://www.healio.com/news/nephrology/20220201/new-therapeutic-agents-may-be-the-holy-grail-for-cardiovascular-risk-management-in-ckd