Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are increasingly prescribed for Type 2 Diabetes Mellitus (T2DM) and cardiorenal protection. However, they are associated with a rare but life-threatening complication known as euglycemic diabetic ketoacidosis (euDKA), which is characterized by ketoacidosis with near-normal blood glucose levels. This often leads to missed or delayed diagnoses. We aim to report a clinical case of SGLT2i-associated euDKA in an elderly patient complicated by acute kidney injury (AKI) and severe hyperkalemia to highlight the diagnostic pitfalls

We present the clinical features, laboratory data, and therapeutic management of an 81-year-old male patient with a history of T2DM, hypertension, and chronic kidney disease, who was being treated with Dapagliflozin 10 mg daily. Clinical information was retrospectively collected from the patient's medical records during his hospitalization for fatigue, and vomiting

The patient presented with a one-week history of poor oral intake and vomiting. Admission laboratory findings revealed a random blood glucose level of 135 mg/dL. Despite the normoglycemia, arterial blood gas analysis indicated severe metabolic acidosis (pH 7.2, HCO3- 9.3 mmol/L). Further evaluation showed severe hyperkalemia (K+ 8.3 mmol/L) and acute-on-chronic kidney injury (Creatinine 11 mg/dL, eGFR 4 mL/min). Blood ketone (beta-hydroxybutyrate) testing confirmed the diagnosis with a significantly elevated level of 6.4 mmol/L. Dapagliflozin was immediately discontinued, and the patient was successfully treated with intravenous fluids, insulin, and management of electrolyte imbalances. Following intensive treatment, the metabolic acidosis resolved, the patient's clinical condition stabilized, and he was subsequently discharged

This case underscores the critical importance of recognizing euDKA in patients on SGLT2i therapy, particularly those with precipitating factors such as starvation and acute renal impairment. Clinicians must maintain a high index of suspicion and assess ketone levels in any patient taking SGLT2i who presents with unexplained metabolic acidosis or nonspecific symptoms, regardless of normal blood glucose levels