Urinary tract infections and sodium-glucose cotransporter 2 inhibitors in heart transplant recipients: a retrospective cohort study
N Alonso De La Fuente, C Fornies Carrizosa, M A Castel Lavilla, P J Caravaca Perez, J J Rodriguez Arias, A Garcia Alvarez, J Casal Rodriguez, E Sandoval Martinez, M Farrero Torres, E Sole GonzalezAbstract
Background
Sodium–glucose cotransporter 2 inhibitors (SGLT2i) improve outcomes in heart failure, but concerns remain regarding urinary tract infections (UTIs). In heart transplant recipients, chronic immunosuppression may increase infection risk, and long-term safety data on SGLT2i are limited.
Purpose
To evaluate the incidence of UTIs and identify predictors of infection in heart transplant recipients treated with SGLT2i.
Methods
We conducted a retrospective, single-centre cohort study including adult heart transplant recipients under follow-up between 2000 and 2025. Patients treated with SGLT2i were compared with non-exposed patients. Clinical variables, UTIs and mortality were identified from medical records. Multivariable logistic regression was used to identify predictors of infection in the overall cohort and among treated patients. Time-to-event analyses were performed to assess infection-free survival.
Results
A total of 253 heart transplant recipients were included, of whom 109 received SGLT2i. Median follow-up after treatment initiation was 2.1 years (interquartile range 1.5–3.0 years). Of the treated patients, 72% received dapagliflozin and 27% empagliflozin. Baseline characteristics and outcomes of both groups are summarised in Table 1 The incidence of UTIs was similar between groups (SGLT2i 19.3% vs no SGLT2i 24.3%, p=0.36), although there was a non-significant trend towards more severe infections in treated patients (35% vs 15%, p=0.15). In multivariable analysis of the overall cohort, female sex (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.24–0.99), lower baseline estimated glomerular filtration rate (OR 0.98 per mL/min/1.73 m²; 95% CI 0.96–1.00), and higher baseline glycated haemoglobin (OR 1.47 per %; 95% CI 1.13–1.91) were independently associated with UTIs, whereas SGLT2i treatment was not (OR 0.52; 95% CI 0.25–1.09). Among SGLT2i-treated patients, baseline glycated haemoglobin showed a non-significant trend as the main predictor of infection. Infection-free survival analysis showed a non-significant trend towards earlier events in treated patients (Figure 1). Treatment was associated with a reduction in glycated haemoglobin and diastolic blood pressure, alongside a modest decline in estimated glomerular filtration rate without changes in proteinuria.
Conclusions
Treatment with SGLT2i was not associated with an increased incidence of UTIs in heart transplant recipients. Infection risk was primarily driven by patient-related metabolic and renal factors rather than treatment exposure. Glycated haemoglobin showed a non-significant trend as a predictor of UTIs in heart transplant recipients treated with SGLT2i. These findings support the use of SGLT2i in this high-risk population, with careful attention to glycaemic control and baseline renal function.Figure1.Infection-free survival accordFor image description, please refer to the figure legend and surrounding text.Table1.Baseline characteristics/outcomesFor image description, please refer to the figure legend and surrounding text.