Fibrates are a commonly used medication in the management of dyslipidemia and cardiovascular risk. These agents have a well-documented association with reversible elevations in serum creatinine and in some instances acute kidney injury. The mechanism underlying the renal effects of fibrates are currently not well understood. We describe a case of acute kidney injury in a patient who was administered an unadjusted dose of fenofibrate in the setting of severe renal impairment. Kidney biopsy demonstrated extensive isometric vacuolization within tubular epithelial cells consistent with osmotic-type injury.