CKD in general practice: SGLT2 inhibitors, the early eGFR dip and when to involve a nephrologist
A new local nephrologist and general physician visited the practice at lunchtime, alongside a pharmaceutical representative. This page pulls out the clinically useful parts: what kind of patients she wants to see, how she handles the expected eGFR dip after starting an SGLT2 inhibitor, the current PBS rules for dapagliflozin in CKD, and her thoughts on new blood pressure drugs in the pipeline. We add short, verified editor notes from Kidney Health Australia, the PBS and the FDA.
A pharmaceutical representative was present and spoke about dapagliflozin (Forxiga) and dapagliflozin with metformin (Xigduo XR). The company was not named on the recording, but the products discussed are AstraZeneca products. The rep thanked the practice for prescribing Forxiga during the year. Statements by the rep are marked as such. This page is not an endorsement of any product, and SGLT2 inhibitors from other companies (for example empagliflozin) have similar CKD evidence and PBS access.
An informal lunchtime introduction of about 20 minutes, not a formal lecture. The Otter file runs 1 hour 45 minutes, but everything after the visitors left (lunch talk and routine clinic work) has been left out completely, as have fees, personal and family details, and any mention of individual patients.
- Visiting specialist
- Dr Rao, nephrologist and general physician. The rep called her "Dr Rao" on the recording. Her description (trained in Melbourne, practice in Miami on the Gold Coast, nephrology and general medicine) matches the public profile of Dr Nisha Rao at Medical on Miami, so we believe this is her, but the first name was not said on the recording. She moved to the Gold Coast about two years ago, her private rooms opened about two months before this visit, and she also works at Tweed.
- Pharmaceutical representative
- Unnamed representative (products discussed: Forxiga, Xigduo XR).
- Practice clinicians
- Practice GPs asked questions (unnamed here).
- Session context
- Otter title Medical Practice and Clinical Discussion · id
5xTWcGifvLQt5iylZJpzWNtE9UI· educational part about the first 21 minutes.
At a glance
| Topic | Key point |
|---|---|
| New referral option | Nephrologist and general physician with space in a new clinic. Takes renal and complex general medicine, but not neurology. |
| Her comfort zone | Cardiorenal and hepatorenal problems, and patients whose fluid management is hard because kidney numbers keep moving. |
| Special interest | Home dialysis, especially peritoneal dialysis (she did a fellowship in it). |
| eGFR dip | Expected in the first few weeks of an SGLT2 inhibitor. She rechecks bloods at about 6 to 8 weeks and warns patients beforehand. |
| PBS | Dapagliflozin CKD criteria widened (verified, from early 2026): albuminuria is no longer needed when eGFR is 25 to under 45. |
| Pipeline | Baxdrostat (oral, FDA approved May 2026) and zilebesiran (6-monthly injection, phase 3). She has a sepsis-related worry about the injection. |
Who to send to this nephrologist
Dr Rao described herself as dual trained in nephrology and general medicine. In her words, most of her general medicine referrals are complex disease management, the kind of patient she also looks after in hospital at Tweed:
- Cardiorenal problems: heart failure and CKD together, where diuretics help the heart but push the creatinine up.
- Hepatorenal problems: liver disease with kidney involvement.
- Patients where fluid management is a struggle "because the kidney numbers are going up and down and everyone's just freaking out". She called this her comfort zone.
- Hypertension that is hard to control, and complex multi-morbidity, which a practice GP noted is growing as people live longer on kidney-protective drugs.
She does not take neurology-focused referrals ("my Achilles' heel"). Her special interest is home dialysis, especially peritoneal dialysis, though she pointed out that by the time someone needs dialysis they would usually already be under a nephrologist.
She said she bulk bills DVA patients and has a lower rate for pensioners. The practice GP asked about out-of-pocket costs; we have left out dollar figures, so check current fees with her rooms before quoting a patient.
SGLT2 inhibitors: why they changed kidney care
Dr Rao reflected on how fast the field has moved: when she was at medical school, kidney protection was "just ACE inhibitors". Now GPs have SGLT2 inhibitors, GLP-1 receptor agonists and more. A practice GP added that with these drugs, dialysis can be postponed for a long time, so patients live long enough to develop other problems.
On how SGLT2 inhibitors protect the kidney, she said they reduce intraglomerular pressure. A GP asked about heart benefits (for example a possible effect on epicardial fat); she said she was not sure of the exact mechanism, but "it just helps with everything".
All the big SGLT2 inhibitor kidney trials were done in people already on an ACE inhibitor or ARB, because that is the established standard. She wondered whether an SGLT2 inhibitor alone might be enough, but stressed she is "not game" to try it: she still uses both, either together or one after the other. Her own habits: perindopril for ACE inhibitor, telmisartan for ARB, dapagliflozin for SGLT2 inhibitor, simply because those are the ones she knows best. If a patient is already on another agent in the class, she leaves them on it.
The early eGFR dip: do not panic
The rep said the most common GP question they hear is about the drop in eGFR after starting an SGLT2 inhibitor. A practice GP added that a physician had once explained that the dip can persist when the drug is started late (for example at an eGFR around 20), but the long-term kidney benefit still holds.
Dr Rao's approach:
- Warn the patient first. Otherwise they come back saying "I came to see you and now my kidneys are worse."
- Do not test in the first two to three weeks, when the dip happens. Seeing the dip makes everyone anxious, even when they know to expect it.
- Recheck at about 6 to 8 weeks. By then the dip has happened and the eGFR has usually come back up, though not always to exactly the same level.
- The drug still slows progression even with the initial dip.
KHA's Chronic Kidney Disease Management in Primary Care handbook (5th edition) says a reversible eGFR drop is expected with SGLT2 inhibitors, greatest about 4 weeks after starting, after which eGFR rebounds, and that specific eGFR testing for this purpose is not required. Because SGLT2 inhibitors cause an osmotic diuresis, KHA suggests considering a lower dose of diuretics or other blood pressure drugs when starting one. Contrast with ACE inhibitors or ARBs, where KHA advises checking eGFR within 2 weeks and stopping and considering referral if eGFR falls more than 25% below baseline. KHA also advises against starting an SGLT2 inhibitor when eGFR is under 25 because of limited evidence (in its heart failure section).
PBS dapagliflozin for CKD: who qualifies now
The rep asked whether the practice was across recent PBS changes for Forxiga. A practice GP summed it up: "you don't need the proteinuria" if the eGFR is below 45. The rep agreed and added that in type 2 diabetes, cardiovascular risk matters more than the HbA1c number alone when choosing therapy.
At its September 2025 meeting the PBAC recommended widening the dapagliflozin CKD listing to match empagliflozin, adding: eGFR 20 to under 25 regardless of UACR; eGFR 25 to under 45 with UACR under 200 mg/g; eGFR 25 to 75 with UACR over 5000 mg/g; and eGFR over 75 to 90 with UACR 200 mg/g or more. Trade press reported the expanded listing from early 2026. The original 2022 listing (eGFR 25 to 75 with UACR 200 to 5000 mg/g) also required the patient to be on a maximum tolerated ACE inhibitor or ARB unless contraindicated, and not on another SGLT2 inhibitor. Check the current restriction text on pbs.gov.au for the exact wording, including any ACE inhibitor or ARB requirement.
Patients outside the PBS criteria
A practice GP asked whether Dr Rao would prescribe an SGLT2 inhibitor privately (non-PBS) for someone with mild kidney involvement who does not meet the criteria, since we know the drug protects the kidney long term.
Her answer was a shared decision. She described a patient type with only low-level albuminuria and an eGFR still above 45: they do not qualify, and it can feel like "waiting for it to become worse" before starting something protective. In that situation she has the conversation; for one such patient, the overall risk of progression was low, so they agreed to wait. Some patients will want to start and pay privately, and that is reasonable.
The rep made a point about PBS coverage for patients with type 2 diabetes on a GLP-1 receptor agonist who also need cardiorenal protection from an SGLT2 inhibitor, but the transcript is garbled here. We have not reported a specific rule. Check the current PBS type 2 diabetes restrictions for combined SGLT2 inhibitor and GLP-1 receptor agonist use.
Diabetes combinations (rep's points)
- Xigduo XR (dapagliflozin with extended-release metformin) "gets forgotten". The rep said it is the only SGLT2 inhibitor and metformin combination taken once a day.
- In type 2 diabetes, the rep's message was that cardiovascular risk should drive the choice, "over and above what the A1c is telling you".
Xigduo XR is PBS listed and taken once daily, usually with the evening meal. Jardiamet (empagliflozin with metformin) is taken twice daily. We did not check every combination product on the market, so treat "the only once-daily one" as the rep's claim.
When to refer: Kidney Health Australia guide
Dr Rao did not list formal referral criteria, so here is the KHA algorithm as a reminder. Her own focus (cardiorenal, hepatorenal, difficult fluid balance, hard-to-control blood pressure) fits naturally alongside these.
New blood pressure drugs in the pipeline
The rep hinted at "a totally new class of drug" for hypertension in about a year but said they could not give details. Dr Rao described two:
- Baxdrostat (AstraZeneca), an aldosterone synthase inhibitor. She said it is already approved in the US and recalled a drop of about 12 mmHg in blood pressure in the trials, which she called "pretty good".
- A six-monthly injection that works on the same system as ACE inhibitors, being studied in trials. (From the description this is likely zilebesiran, an siRNA that silences angiotensinogen; she did not name it.)
The appeal is obvious: no reliance on daily tablets. A practice GP compared it with inclisiran, the twice-yearly cholesterol injection. But Dr Rao's concern is what happens when a patient becomes septic or hypotensive. With a tablet ACE inhibitor you simply stop it. With a long-acting injection "floating in your body" there is no off switch unless there is an antidote, and she wondered whether more of these patients might need vasopressors (she mentioned metaraminol) in hospital. She stressed this is a personal reservation and the data may prove it unfounded.
Baxdrostat: the US FDA approved Baxfendy (baxdrostat) on 15 May 2026 for adults whose hypertension is not controlled on other drugs, used in combination with them, at 2 mg daily (1 mg if at higher risk of high potassium or low sodium). In the BaxHTN trial the placebo-adjusted fall in office systolic BP at 12 weeks was about 9 to 10 mmHg (8.7 mmHg for 1 mg, 9.8 mmHg for 2 mg), so the speaker's "12 mmHg" is a little higher than the FDA figure. We did not confirm an Australian TGA registration; check before discussing with patients.
Zilebesiran (Alnylam with Roche): 300 mg under the skin every 6 months, now in the global phase 3 ZENITH outcomes trial (about 11,000 patients), with results expected around 2030. Not available in Australia.
Inclisiran (Leqvio) is PBS listed with authority for selected patients with high LDL cholesterol despite statin and ezetimibe, which matches the GP's "only for a subgroup".
Sick day rules: KHA's SADMANS list (sulfonylureas, ACE inhibitors, diuretics, metformin, ARBs, NSAIDs, SGLT2 inhibitors) are withheld during acute illness with dehydration, sepsis or low blood pressure. That is exactly the step a six-monthly injection would not allow, which is the heart of Dr Rao's concern.
Stem cells for kidney failure?
A practice GP asked whether there is any evidence for stem cell treatment in failing kidneys, noting claims for liver cirrhosis. Dr Rao said she would need to look again, but she knows of nothing convincing. When she last looked into it, a couple of years ago, she found no proper published evidence, and she had seen a very poor outcome after an unproven overseas stem cell treatment. The GP added that such treatments are often sought as a last resort.
If a patient with CKD asks about stem cell clinics, it is fair to say that specialists do not see convincing evidence, that these treatments can be expensive, and that serious harm (including infection) has been seen. Encourage them to discuss it with their nephrologist first.
GP takeaways
1. A new local nephrologist and general physician has capacity: think of her for cardiorenal, hepatorenal and difficult fluid balance patients, hard-to-control hypertension and home dialysis questions. Not for neurology.
2. Before starting an SGLT2 inhibitor, tell the patient to expect a small eGFR dip. Recheck at about 6 to 8 weeks rather than in the first 2 to 3 weeks, and consider easing diuretics.
3. PBS dapagliflozin for CKD is broader now: eGFR 25 to under 45 no longer needs albuminuria, and eGFR 20 to under 25 qualifies regardless of UACR. Check the full restriction.
4. For patients outside the criteria, have a risk-based conversation about private prescribing.
5. Keep using an ACE inhibitor or ARB plus an SGLT2 inhibitor; the specialist still uses both.
6. Remind patients on these drugs about sick day rules (SADMANS).
7. Watch for baxdrostat and, later, zilebesiran; neither is available in Australia yet as far as we could confirm.
Transcript caveats
Name: the specialist was called "Dr Rao" once on the recording. The first name Nisha comes from a public profile that matches her description, not from the recording.
Drug names: Otter wrote "Fossiga" or "Foseger" (Forxiga), "Ziggio" (Xigduo), "Baxendi" (Baxfendy, baxdrostat). The six-monthly injection was not named; zilebesiran is our inference.
Left out on purpose: fees in dollars, personal and family details, the names of other doctors and staff, a local hospital education event, the specialist's account of an individual patient (summarised only in general terms), and the whole second part of the recording after the visitors left, which was lunch conversation and routine clinic work involving patients. No patient information appears on this page.
Unclear: the rep's exact point about PBS cover with GLP-1 receptor agonists; the units of the UACR value in her example.