BackgroundSodium‐glucose co‐transporter‐2 inhibitors (SGLT2is) reduce cardiovascular risk in people with diabetes and established cardiovascular disease, but emerging studies in chronic kidney disease (CKD) have inconsistent results. In this systematic review, we evaluate the effects of SGLT2is on cardiovascular mortality in people with CKD as a whole and across subgroups stratified by baseline kidney function and among people at low, moderate, high and very high risk according to KDIGO‐ CKD classification system.MethodsLiterature search was conducted in PubMed/MEDLINE, Cochrane/CENTRAL, Scopus and Web of Science up to 30 November 2023. We included randomized controlled trials assessing the effect of SGLT2is on cardiovascular mortality in people with CKD. Secondary outcomes included all‐cause mortality and major adverse cardiac events (MACE).ResultsEleven studies (n = 83,203 participants) were included. In people with CKD, treatment with SGLT2is compared to placebo reduced the risk of cardiovascular death by 14% (hazard ratio [HR] .86; 95%CI .79–.94), all‐cause death by 15% (HR .85; 95%CI .79–.91) and MACEs by 13% (HR .87; 95%CI .81–.93). A consistent treatment effect was observed across eGFR‐subgroups (≥60 mL/min/1.73 m2: HR .82, 95%CI .65–1.02; <60 mL/min/1.73 m2: HR .86, 95%CI .77–.96, p‐subgroup difference = .68) and KDIGO risk‐categories (low, moderate, high and very high) (p‐subgroup difference = .69) for cardiovascular death; reduction in the risk of all‐cause death tended to be greater in the highest KDIGO risk categories. A consistent treatment effect on cardiovascular mortality was observed for different SGLT2is agents studied. Sensitivity analysis for cardiovascular mortality endpoint including studies in diabetic people yielded similar results (HR .86; 95%CI .77–.97).ConclusionsTreatment with SGLT2is led to a significant reduction in the risk of cardiovascular and all‐cause mortality in people with different CKD stages. These findings support the use of SGLT2is as an adjunct cardiovascular protective therapy in CKD.PROSPERO Registration NumberPROSPERO registration number: CRD42022382863.
