From glucosuria to dialysis: a case report of osmotic nephropathy due to an SGLT2 inhibitor

Osmotic nephropathy is a rare histopathological diagnosis associated with exposure to hyperosmolar agents, as exemplified by this case related to empagliflozin use. The proposed pathophysiological mechanism involves lysosomal uptake secondary to increased intratubular osmotic pressure caused by glucosuria. Predisposing factors include therapy with SGLT2 inhibitors, diabetes mellitus, advanced age and pre-existing mild chronic kidney impairment. The cornerstone of management is discontinuation of the offending agent and supportive measures. It is recommended that SGLT2 inhibitors be withheld during episodes of diarrhea or acute dehydration to prevent further renal impairment.