If this study has a cardio protective effect it will affect the mortality and morbidity of advanced CKD patients and improve their quality of life

Cardiovascular disease is the leading cause of mortality, accounting for >50% of deaths with known causes, while cardiovascular mortality is 9-fold higher in these patients compared with age- and sex-matched individuals in the general population Particularly, heart failure poses a significant challenge in the management of ESKD. It frequently develops after initiation of dialysis and is a prominent mortality risk factor among these patients When CKD patients develop HF, increased sodium and fluid retention, and vascular tension will lead to increased preload of the heart. The increased ventricular wall pressure will lead to release biomarkers like natriuretic peptides (NP). Therefore, biomarkers of myocardial stretch are commonly used in the diagnosis and prognosis evaluation of HF. It is worth noting that the negative predictive value of NP is extremely high (0.94-0.98), while the positive predictive value is slightly lower, (0.44-0.57) for chronic heart failure (CHF) and (0.66-0.67) for acute heart failure (AHF), Commonly used myocardial stretch marker include NT-pro BNP .

NT-pro BNP has the advantage that Accuracy of negative diagnosis is extremely high; The prognostic value is the most powerful, especially in CKD stages 4-5 and dialysis patients Traditional therapies to prevent CVD complications in the general population have shown to be ineffective in Chronic kidney disease (CKD). To address the unmet need, further research is needed to evaluate novel therapeutic strategies to improve cardiovascular outcomes among patients on dialysis .

Over the last several years, Sodium-glucose transporter type 2 (SGLT2) inhibitors have been shown to confer substantial kidney and cardiovascular benefits among patients with type 2 diabetes, heart failure, and/or high-risk CKD .

Secondary analyses from these landmark trials demonstrated consistent benefits of SGLT2 inhibitors across many subgroups, supporting the widespread use and incorporation in clinical practice guidelines of this new kidney and cardio protective drug class.

Inclusion Criteria:

• Patients with CKD stage5 (i.e., eGFR < 15 mL/min/1.73m2) (Inker et al., 2021)

Exclusion Criteria:

• patients who refuse to sign consent
• Patients with acute heart failure , will exclude patients with known prior ischemic heart diseases or ischemic cardiomyopathy
• Autosomal dominant polycystic kidney disease (ADPKD).
• Type 1 diabetes mellitus
• History of ketoacidosis in the last year.
• Known hypersensitivity to SGLT2 inhibitors.
• Known severe hepatic impairment (Child-Pugh class C)
• Pregnant or breastfeeding females