Poster Presentation Australian Diabetes Society and the Australian Diabetes Educators Association Annual Scientific Meeting 2017

Diabetic ketoacidosis (DKA) in patients on maintenance dialysis: case series and literature review (#297)

Emma Croker 1 , Hong Lin Evelyn Tan 1 2 , Christopher W Rowe 1 2 3
  1. Department of Endocrinology and Diabetes, John Hunter Hospital, New Lambton, NSW, Australia
  2. School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
  3. Hunter Medical Research Institute, Newcastle, NSW , Australia

Background: DKA in the setting of maintenance dialysis (MD) is uncommon, and is not addressed by standard management algorithms.

Methods: Retrospective review of adult cases of DKA in MD patients presenting to a regional tertiary hospital over 10 years, identified by ICD10 search (confirmed with manual review); compared with cases of DKA in patients without MD.

Results: Of 630 cases of DKA, 11 (1%) occurred in MD patients. Compared with non-MD cases, MD cases were older (32 vs 44yrs; p=0.01), had an increased length-of-stay (median 2 vs 5 days, p=0.01), and higher mortality trend (2% vs 9%; p=0.09). An illustrative case series is presented. Case 1: 60yo male on peritoneal dialysis (PD) with severe DKA (pH 6.95, HCO3 5mmol/L, anion gap >47mEq/L, betahydroxybutyrate 9mmol/L, lactate 11mmol/L, glucose 73mmol/L, compensatory hypontraemia 125mEq/L, symptomatic hyperkalaemia 8mmol/L). Hyperkalemia was treated with bolus IV insulin followed by rapid PD exchanges, which additionally rapidly corrected acidosis. Ketosis and hyperglyceamia were corrected with slow IV insulin (3-5units/hr), allowing osmotic adjustment. 5L IV fluid and 40mmol potassium were required over 24hrs. Case 2: 49yo female on haemodialysis presenting with mild DKA (pH 7.26, betahydroxybutyrate 5mmol/L, glucose 50mmol/L, potassium 5.3mmol/L); treated with 2-5 units/hr IV insulin (no potassium or IV fluids). Dialysis deferred for 24hrs. Case 3: 28 year old female on HD with mild DKA (pH7.23, HCO3 17mmol/L, betahydroxybutyrate 4mmol/L, glucose 27mmol/L), treated with 0.5-5U/hr insulin (initially 5U/hr), 3L IV fluid and 20mmol potassium required over 24hrs. Routine dialysis 24 hours later.

Discussion: DKA in MD is rare, and requires specialized management. Cases can often be managed with intravenous insulin alone, as a lack of osmotic diuresis results in minimal fluid and potassium deficits.1-3 Slow correction of hyperosmolar status is imperative. Severe cases require judicious fluid and electrolyte replacement. Dialysis prescription must be individualized.  

  1. Rohrscheib, M., Tzamaloukas, A.H., Ing, T.S., Siamopoulos, K.C., Elisaf, M.S. & Murata, H.G. (2005) Serum potassium concentration in hyperglycemia of chronic dialysis. Advances in Peritoneal Dialysis 21, 102-105.
  2. Tzamaloukas, A.H., Ing, T.S., Siamopoulos, K.C., Rohrscheib, M., Elisaf, M.S., Raj, D.S. & Murata, G.H. (2008) Body fluid abnormalities in severe hyperglycemia in patients on chronic dialysis: review of published reports. Journal of Diabetes and Its Complications 22, 29-37.
  3. Tzamaloukas, A.H., Ing, T.S., Elisaf, M.S., Raj, D.S., Siamopoulos, K.C., Rohrscheib, M. & Murata, G.H. (2011) Abnormalities of serum potassium concentration in dialysis-associated hyperglycemia and their correction with insulin: review of published reports. International Urology and Nephrology 43, 451-459.