SGLT2 inhibitors as a strategy for volume management in peritoneal dialysis: a case series

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have demonstrated cardiovascular and renal benefits in chronic kidney disease, yet their role in peritoneal dialysis (PD) remains largely unexplored, and clinical experience is limited. We describe, at the individual-patient level, seven consecutive patients treated with an SGLT2i at a single centre (median age 69 years, range 43-73; five men; one with type 2 diabetes; six dapagliflozin, one empagliflozin). The PD prescription was not modified during treatment, and ultrafiltration refers to the 24-hour drained volume. In the four patients in whom the drug was added to established, unchanged PD, ultrafiltration rose in three and fell in one; the single non-responder was also the only low-average transporter and was later transferred to haemodiafiltration. Both patients anuric at baseline increased their ultrafiltration, and in one of them PD was the only feasible modality. Peritoneal transport category was unchanged wherever paired equilibration tests were available. Serum urate fell in the patients with preserved diuresis but not in those who were anuric, whereas the largest ultrafiltration gain occurred in a patient anuric throughout, dissociating the peritoneal response from any renal effect. The erythropoietin resistance index fell in all treated patients, although the magnitude was clinically relevant in a minority and must be read alongside the haemoglobin trajectory. No patient developed anuria de novo. One patient died of fungal peritonitis in the context of documented non-adherence, an event reported here with its mechanistic implications. These observations support a direct peritoneal mode of action and warrant prospective evaluation with surveillance for fungal infection.