Dapagliflozin: Ally or Risk?

Introduction: Since its introduction, dapagliflozin has been widely used in nephrotic syndrome due to its nephroprotective effect and its ability to delay the progression to end-stage chronic kidney disease. However, its use is not always appropriate, as its effectiveness may vary depending on the patient's clinical context. Case Description: We present the case of a 64-year-old woman with no medical history who began experiencing fatigue, weakness, lack of energy, oliguria, and ascending bilateral lower limb edema, which progressed to anasarca accompanied by diffuse abdominal pain. Laboratory studies revealed proteinuria with an albumin/creatinine ratio >3800 mg/g, total cholesterol of 386.9 mg/dL, and serum albumin of 2.24 g/dL, confirming the diagnosis of nephrotic syndrome. Treatment was initiated with telmisartan, furosemide, and methylprednisolone boluses. After conducting the necessary studies to rule out secondary causes of nephrotic syndrome, the patient was hospitalized and a kidney biopsy was performed. Electron microscopy revealed diffuse podocyte foot process effacement in over 90%, a finding consistent with minimal change disease. During her hospital stay, dapagliflozin was added to the treatment regimen; however, within 24 hours, a progressive increase in creatinine from 1.01 mg/dL to 2.8 mg/dL over one week was observed. Due to this elevation, the drug was discontinued, and a gradual decrease in creatinine levels followed. Subsequently, after clinical stabilization, dapagliflozin was reintroduced without any further adverse effects during the next 20 weeks. Discussion: In 2016, the FDA issued a warning regarding the use of SGLT2 inhibitors in patients with pre-existing kidney disease and the risk of developing acute kidney injury (AKI). The study by Cabral Lopes, et al. [1] showed an increased risk of AKI when combining dapagliflozin with furosemide in hospitalized patients with prior kidney disease, in line with Perlman, et al.'s [2] findings on the association between SGLT2 inhibitors, diuretics, and AKI. This case highlights the importance of individualizing treatment. Although dapagliflozin offers nephroprotective benefits, its initiation should be delayed until clinical stabilization in patients with nephrotic syndrome. Additionally, the concurrent use of diuretics should be considered carefully, as it may increase the risk of developing acute kidney injury.