SGLT2 Inhibitors and Liver Cirrhosis: Hype or Hope?

Liver cirrhosis is marked by sodium and water retention, portal hypertension and sharply reduced survival after decompensation. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) induce insulin-independent glycosuria and natriuresis and have proven cardio-renal benefits, prompting interest in their role as adjuncts for ascites. This review synthesizes current evidence on efficacy, safety and mechanistic plausibility of SGLT2i in cirrhosis. Observational cohorts and case series suggest that adding SGLT2i to standard diuretics increases natriuresis, lowers ascites burden and paracentesis requirements, improves weight and aminotransferases and may reduce hepatic decompensation and hepatocellular carcinoma risk. Safety remains paramount: hypotension, acute kidney injury and hepatorenal syndrome-related acute kidney injury, genitourinary infections, electrolyte disturbances and rare euglycemic ketoacidosis necessitate careful patient selection, slow titration and close monitoring, especially in decompensated disease and when combined with loop diuretics or mineralocorticoid receptor antagonists. Overall, the balance of data supports cautious optimism: SGLT2i represent a promising adjunct within protocolized care pathways for selected patients, while definitive trials powered for hepatic outcomes are still required to clarify indications, timing, dosing and long-term impact.