Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor- and Metformin-Associated Euglycemic Diabetic Ketoacidosis and Lactic Acidosis Leading to Refractory Acute Kidney Injury: Successful Management With Hemodialysis

Euglycemic diabetic ketoacidosis (EuDKA) is a rare but serious complication of sodium-glucose cotransporter 2 (SGLT2) inhibitors, characterized by metabolic acidosis with near-normal blood glucose levels, making it challenging to diagnose. This case report describes a 49-year-old male with stage 4 chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM) on an SGLT2 inhibitor and metformin who developed EuDKA and lactic acidosis following an upper respiratory infection. Despite discontinuation of the medications and intravenous fluid resuscitation, severe metabolic acidosis persisted. Early initiation of hemodialysis led to rapid correction of acidemia, hyperkalemia, and improvement in renal function. This case highlights the importance of early recognition of SGLT2 inhibitor-associated EuDKA, particularly when complicated by lactic acidosis, and emphasizes the potential role of hemodialysis in managing refractory metabolic acidosis to prevent further clinical deterioration, even with modest hyperglycemia.