Morgan Oskutis, MD
Dr
Emory University School of Medicine, United States
Disclosure information not submitted.
Jonathan Suarez, MD
Assistant Professor
Emory University, United States
Disclosure information not submitted.
Title: Euglycemic DKA Despite Use of Glucose-Containing Dialysate for CRRT: A Rare But Known Event
Introduction: Continuous renal replacement therapy (CRRT) can be a precipitating factor in the development of euglycemic diabetic ketoacidosis (DKA) given the water-soluble nutrient loss that occurs. Most case reports describing the occurrence of euglycemic DKA in the setting of CRRT occur when glucose-free dialysate is used. This case report describes a patient with euglycemic DKA despite the use of glucose-containing dialysate and further highlights that euglycemic DKA remains a challenging diagnosis.
Description: A 73 year-old male with a medical history notable for diabetes mellitus and end-stage renal disease on hemodialysis presented with one week of abdominal pain, vomiting, and diarrhea. The patient had signs of shock with peritonitis on abdominal examination. Advanced imaging was obtained revealing pneumoperitoneum. The patient was taken for an exploratory laparotomy which found a perforated sigmoid diverticula. A sigmoid colectomy with an end-colostomy was performed. The patient was admitted to the Intensive Care Unit post-procedure. Over the proceeding days, the patient continued to have multi-organ failure with the development of copious ostomy output. Laboratory findings demonstrated euglycemia with a persistent mild lactic acidosis (1.5-4.0 mmol/L), a low bicarbonate level (15-22 mmol/L), and an elevated anion gap metabolic acidosis (20 – 34). Volume resuscitation continued with eventual normalization of the lactate. An isotonic bicarbonate drip was started to account for the diarrheal losses. Hemodialysis, initially intermittent with transition to continuous venovenous hemodiafiltration using a glucose-containing solution, corrected the patient’s uremia. Citrate toxicity was ruled out. Despite such interventions, laboratory findings continued to show an elevated anion gap metabolic acidosis. On hospital day 9, a beta-hydroxybutyrate was obtained with the value being above the upper limit of detection. The patient was initiated on 20 percent dextrose and insulin infusion with correction of the metabolic abnormalities followed by an improvement in the clinical exam.
Discussion: Euglycemic DKA can occur despite the use of a glucose-containing dialysate solution. Ketoacidosis should be strongly considered in diabetic patients on CRRT with a metabolic acidosis even in the presence of normoglycemia.