Differential Effects of SGLT2 Inhibitors on Contrast-Associated Acute Kidney Injury According to Hemoglobin and Age: A Propensity-Score Matched Analysis

Objectives : Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are widely used in type 2 diabetes, heart failure, and chronic kidney disease. Given their expanding indications, SGLT2i are increasingly prescribed to patients undergoing contrast-enhanced procedures. However, their impact on contrast-associated acute kidney injury (CA-AKI) remains uncertain. We evaluated the overall risk of CA-AKI in SGLT2i users and identified clinical effect modifiers.
Methods : In this single-center propensity-score matched study (2007–2025), 346 SGLT2i users and 1,979 matched non-users were selected from 7,853 angiography patients using variable-ratio matching (caliper 0.2). Weighted logistic regression with multiple imputation (m=5) was performed. Interaction models were used to identify effect modification.
Results : The overall incidence of CA-AKI was similar in SGLT2i users (9.25%) and non-users (9.20%; adjusted OR 0.89, 95% CI 0.54–1.49, P=0.661). Hemoglobin (Hb) significantly modified the association (interaction OR 0.754 per 1 g/dL increase, P-interaction=0.023); the adjusted odds ratio crossed 1.0 at an estimated Hb level of 11.2 g/dL. SGLT2i use was associated with higher risk below this threshold and lower risk above it. Age also significantly modified the association (interaction OR 1.036 per year, P-interaction=0.037), with the interaction curve crossing the null at 72.4 years. A significant interaction by sex was observed (P-interaction=0.022), with a trend toward higher risk among females.
Conclusions : While the overall association between SGLT2 inhibitor use and CA-AKI was neutral, baseline hemoglobin and age significantly modified this association. Periprocedural SGLT2i management may require individualized consideration, particularly in elderly patients with low hemoglobin levels.