Emphysematous Kidney Related to the Use of Empagliflozin in a Diabetic Woman

BACKGROUND/OBJECTIVE: Sodium-glucose cotransporter-2 (SGLT2) inhibitors are part of the treatment for hyperglycemia in patients with diabetes. These drugs have shown important benefits including cardiovascular and renal protection among people with diabetes. CASE REPORT: We report a case of a 60-year-old woman with diabetes who presented to the emergency department complaining of left flank pain radiating to the groin. The patient was on multiple antidiabetic medications, including a recently added empagliflozin, considering the difficulty in controlling hyperglycemia. She quickly developed severe sepsis with shock, and imaging studies of the abdomen revealed the presence of encapsulated gas in the left kidney compatible with emphysematous pyelonephritis (EPN). There was no presence of nephrolithiasis or other anatomical or structural abnormality that could have precipitated this focal renal infection. Besides antimicrobials, fluid resuscitation, and vasopressor agents, an emergent surgical nephrectomy, as well as intensive care, was required until the patient fully recovered. Escherichia coli was isolated from the initial blood cultures, and ceftriaxone was administered. The patient was subsequently discharged home in stable condition. Two months later, the patient was readmitted with near-syncope and abdominal pain, which was found to be related to small bowel obstruction. The patient decompensated rapidly and had a cardiac arrest even before surgical evaluation. She was resuscitated and admitted to the intensive care unit but showed no signs of neurologic recovery after the anoxic event. She did not survive this hospitalization. DISCUSSION: The exposure of SGLT2 inhibitors in this patient seemed to have been the precipitating factor for development of complicated pyelonephritis with gas gangrene. EPN is a consequence of a severe renal parenchymal infection, which carries high mortality even with prompt treatment. CONCLUSION: Use of SGLT2 inhibitors has expanded worldwide as there are clear clinical benefits, but we need to recognize their uncommon yet potentially fatal complications, such as EPN.