The Utilization of Hemodialysis in the Treatment of Severe DKA Case

Presentation Number: SAT 607
Date of Presentation: April 1st, 2017

Omar Mohamad Jawhar1, Muhammad Abid Ulhaque2, Kranthi Andhavarapu3, Abdul I Mahmad4, Mohamad Wisam Albaghdadi5, Peter Santos6 and Mohamad Hosam Horani*7
1Midwestern University, 2A.T. Still University, 3Banner Baywood Hospital, 4banner Baywood Hospital, 5Banner Thunderbird Hospital, 6AKDHC nephrology, 7Alsham Endocrinology, Chandler, AZ

Abstract

 

Diabetic Ketoacidosis (DKA) is a potentially life threatening complication for both type 1 and 2 diabetes mellitus. The pathology of this condition is well understood and management of DKA is well established. Patients who present with severe DKA require an intensive monitoring and aggressive treatment. Hemodialysis can strategically be used in cases of severe ketoacidosis.

We report a case of a 41 year old AA female with a history of Type I diabetes and several episodes of DKA in the past. Prior to her presentation to the hospital, she had extensive debridement of facial mucormycosis and implementation of Amphotericin B treatment. Upon presentation to the hospital, she was in severe prerenal state as result of poor oral intake and diarrhea for 2 weeks. She was in septic shock and acute renal failure requiring intravenous fluid (IVF) resuscitation and vasopressor support. Additionally, she was subsequently intubated due to her altered mental status. Her laboratory results were as follows: glucose 315, creatinine of 1.46, anion gap of 20 and C02 of 8, sodium 145, potassium 1.8, calcium 6.8, phosphorous 1.0, and lactic acid 4.7. ABG showed pH 7.161, pCO2 10.9, HCO3 7.3. 

Despite aggressive management with continuous insulin drip and IVF, DKA remains unresolved. Additionally, sodium bicarbonate infusion (D5 0.45% NS with 75 mEq of sodium bicarbonate) was initiated to address persistent metabolic acidosis. The institution of insulin drip and sodium bicarbonate IVF resulted in difficult to correct hypokalemia regardless of aggressive potassium supplementation. Due to uncontrollable ketoacidosis and hypokalemia, hemodialysis (HD) was initiated to address these acid-base disturbance and electrolyte abnormality. Patient received four sessions of HD resulting in correction of ketoacidosis and hypokalemia and re-initiation of insulin to manage her diabetes.

 

This case illustrates the difficulty in managing a serious acid-base and electrolyte abnormalities that can occur in patients presenting severe DKA. Hypokalemia is common during the treatment of DKA as result of insulin. However, severe hypokalemia at presentation prior to insulin treatment is exceedingly uncommon and can occur in cases of gastrointestinal potassium loss or poor nutritional status. Patients with DKA are expected to have total body potassium depletion, but measured levels may be normal or elevated due to extracellular shifts of potassium secondary to acidosis. In a large prospective cross-sectional descriptive study of DKA patients with a capillary blood glucose level of 250 mg/dL or higher, hypokalemia was observed in only 5.6%. The utilization of hemodialysis is an unconventional therapeutic management of DKA, and it should only be seriously considered in extreme cases of DKA when both ketoacidosis and hypokalemia are not manageable by standard of care. 

 

Nothing to Disclose: MOJ, MAU, KA, AIM, MWA, PS, MHH