Kidney International · Nov 11, 2026

Metabolic Unloading: How SGLT2i Recalibrate Cell Energetics to Slow CKD Progression

By Leon VM, Aggarwal S

Kidney outcome trials demonstrate that sodium–glucose cotransporter 2 inhibitors consistently slow chronic kidney disease progression; however, the underlying mechanisms remain incompletely defined, as benefits extend beyond glycemic control and hemodynamic effects across diabetic and non-diabetic chronic kidney disease. This review advances a unifying framework in which metabolic unloading of the proximal tubule contributes to renoprotection. The metabolic burden of solute reabsorption places the proximal tubule at the center of renal energetics, predisposing it to hypoxia, mitochondrial stress, and maladaptive injury responses. We synthesize evidence that these agents reduce adenosine triphosphate-dependent transport workload, oxygen consumption and may also reduce megalin-dependent endocytosis, with downstream effects on mitochondrial efficiency, redox balance, and autophagy/mitophagy supported by emerging preclinical data. By mitigating energetic stress, these agents divert tubular cell fate away from maladaptive hypertrophy and fibrosis toward adaptive repair. This framework integrates spatial cortex–medulla vulnerability, reconciles early hemodynamic changes with durable slowing of estimated glomerular filtration rate decline, and explores disease-agnostic benefit. We discuss translational implications including early initiation, identification of high workload phenotypes (hyperfiltration, recovery after acute kidney injury), and deployment of energetics associated biomarkers such as ketones, oxidative stress profiles, and estimated glomerular filtration rate slope. This review positions cellular energetics as an important upstream constraint shaping kidney disease progression, offering a foundation for nephroprotective strategies.

doi.org/10.1016/j.kint.2026.10.018PubMed 43014444Interventions