Kidney Week

Abstract: SA-PO0603

Successful Management of Refractory Hypomagnesemia with Renal Magnesium Wasting Using Combination SGLT2 Inhibitor and Amiloride Therapy

Session Information

• Fluid, Electrolyte, and Acid-Base Disorders: Case Reports - 2
  October 24, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Fluid, Electrolytes, and Acid-Base Disorders

• 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

• Khaliq, Muhammad, The University of Tennessee Health Science Center Department of Medicine, Memphis, Tennessee, United States

Muhammad Khaliq, MD, MBBS

• Rustom, David S., The University of Tennessee Health Science Center Department of Medicine, Memphis, Tennessee, United States

David S. Rustom, MD

• Jan, Muneeb Ullah, The University of Tennessee Health Science Center Department of Medicine, Memphis, Tennessee, United States

Muneeb Ullah Jan, MD

• Rafaey, Wania, The University of Tennessee Health Science Center Department of Medicine, Memphis, Tennessee, United States

Wania Rafaey, MD, MBBS

• Gyamlani, Geeta G., The University of Tennessee Health Science Center Department of Medicine, Memphis, Tennessee, United States

Geeta G. Gyamlani, MD, FASN

• Adeboye, Adedamola M., The University of Tennessee Health Science Center Department of Medicine, Memphis, Tennessee, United States

Adedamola M. Adeboye, MD, MBBS

Introduction

Beyond the known antidiabetic, renal protective, and cardioprotective effects of SGLT2 inhibitors, their use continues to reveal additional benefits on a broader scale. In this case, we present a patient with renal magnesium wasting refractory to high-dose oral magnesium replacement as well as amiloride with improvement only once empagliflozin was added.

Case Description

A 70-year-old male with CKD stage IIIb due to diabetes and hypertension presented with chronic persistent hypomagnesemia despite high-dose oral magnesium supplementation. Risk factors included chlorthalidone therapy, PPI use, and prior abdominal surgeries. High fractional excretion of magnesium at 4.98% confirmed renal magnesium wasting. After discontinuation of chlorthalidone and PPI, serum magnesium remained low in the 1.1-1.3 mg/dL range. Amiloride did not improve levels. However, addition of empagliflozin led to nearly normalized magnesium in the 1.5-1.6 mg/dL range. Renal function remained stable in the CKD stage IIIb range.

Discussion

This case illustrates the complex management of refractory renal magnesium wasting in a patient with multiple contributing factors and potentially a genetic component. Prolonged thiazide use can reduce TRPM6 activity in the distal convoluted tubule, and this can be exacerbated by uncontrolled diabetes with osmotic diuresis. Our patient remained hypomagnesemic after stopping the thiazide, so this does call into question a genetic etiology as well. In this case, empagliflozin produced clinically meaningful improvement where other strategies failed. SGLT2 inhibitors are thought to improve insulin sensitivity, thereby restoring TRPM6-mediated magnesium reabsorption. This case supports a possible advantage of SGLT2 inhibitors for renal magnesium wasting especially in the setting of CKD due to a more favorable safety profile and renal protective effects. Further research could evaluate their efficacy head-to-head against longer-established therapies such as potassium sparing diuretics as well as investigate possible synergism between these medication classes.