Abstract
Background: Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) have been shown to provide protective effects in patients with type 2 diabetes, heart failure, and chronic kidney disease. Evidence on their impact in the perioperative setting, particularly in cardiac surgery, however, remains scarce, thus, we aimed to evaluate the association between preoperative SGLT-2i use and postoperative outcomes in patients undergoing major cardiac surgical procedures.

Methods: This retrospective, single-center study included adult patients with SGLT-2i therapy, who underwent cardiac surgery between 2020 and 2024. The exposure was defined as documented SGLT-2i use within 14 days before surgery. The primary endpoint was postoperative acute kidney injury (AKI) defined according to KDIGO criteria; secondary endpoints included need for kidney replacement therapy, ICU length of stay, and 30-day mortality. A causal inference framework employing inverse probability of treatment weighting was applied to estimate the effect of SGLT-2i therapy.

Results: Of the study population (n=1257), 211 (16.8%) were female. Four hundred eighty two (38.3%) patients were SGLT-2i users and 775 (61.7%) non users. Users had a EuroSCORE II (median 2.5 [1.4–4.9] vs. 1.5 [0.9–2.6], p<0.001), and more frequent chronic kidney disease and heart failure. Baseline creatinine was higher among users, while preoperative hemoglobin was lower. Thirty-day survival did not differ significantly between groups (97.0% vs. 98.3%, p=0.253).

Conclusion: In patients undergoing cardiac surgery, preoperative SGLT-2i use was associated with distinct baseline characteristics including higher comorbidity burden. While mortality did not differ, the causal inference framework will allow for robust estimation of the therapy’s effect on postoperative AKI risk. These findings contribute to the growing body of evidence on the potential perioperative benefits of SGLT-2i and support the need for prospective validation.