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Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have cardioprotective and renoprotective effects. However, experience with SGLT2i in diabetic kidney transplant recipients (DKT) is limited. Methods This observational multicentre study was designed to examine the efficacy and safety of SGLT2i in DKTR. The primary outcome was adverse effects within 6 months of SGLT2i treatment. Results Among 339 treated DKTR, adverse effects were recorded in 26%, the most frequent being urinary tract infection (UTI) (14%). In 10%, SGLT2i were suspended mostly because of UTI. Risk factors for developing UTI were a prior episode of UTI in the 6 months leading up to SGLT2i onset [OR 7.90 (CI 3.63–17.21)] and female sex [OR 2.46 (CI 1.19–5.03)]. In a post-hoc subgroup analysis, the incidence of UTI emerged as similar in diabetic kidney transplant recipients treated with SGLT2i for 12 months than non-diabetic kidney transplant recipients (17.9% vs 16.7%). Between baseline and 6-month, significant reductions were observed in body weight [─2.22 (─2.79, ─1.65) kg], blood pressure, fasting-glycemia, HbA1c [─0.36 (─0.51, ─0.21) %], serum uric acid [─0.44 (─0.60, ─0.28) mg/dl] and urinary protein/creatinine ratio, while serum magnesium [+0.15 (0.18, 0.11) mg/dl] and hemoglobin levels rose [+0.44 (0.28–0.58]. These outcomes persisted in participants followed over 12 months of treatment. Conclusions SGLT2i in KT offers benefits in terms of controlling glycemia, weight, blood pressure, anemia, proteinuria, and serum uric acid and magnesium. UTI was the most frequent adverse effect. According to our findings, these agents should be prescribed with caution in female DKTR and those with a history of UTI.

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We have read the article written by Ison et al. 1 that has raised some issues we would like to discuss. COVID-19 breakthrough infection rates in vaccinated kidney transplant (KT) recipients much higher than in the general vaccinated population have been reported. 2 Furthermore, the severity remains markedly high. Although Ison et al. referred cases are rarely severe, other series, and among them, the largest cohort published so far, have reported 27% of very serious cases. 3 By August 2021, 843 KT recipients at our center have been fully vaccinated against COVID-19. During this period, 15 patients developed COVID-19 after two doses of mRNA-based vaccines: 1.8% versus 0.01% in the general population. 2 Of them, five needed hospitalization (33.3%): three remain in critical care units and one died. Contrary to what Ison et al. stated, also in our experience, severe COVID-19 has not been uncommon in infected vaccinated KT patients.

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