Introduction: Diabetes mellitus is the commonest cause of chronic kidney disease leading to end-stage renal failure (ESRF). Fluid replacement is one of the cornerstone treatments of DKA, however anuric dialysis patients are at risk of fluid overload. Information for managing DKA in haemodialysis patients is relatively sparse.
Case report: A 76-year-old gentleman with type 1 diabetes was admitted with drowsiness. He has twice weekly dialysis and on 700 ml/day fluid restriction. Due to recurrent episodes of hypoglycaemia, his insulin dose was reduced. On examination he had dry mucous membranes, cool peripheries and erythematous left below knee amputation stump. Blood pressure was 92/50 mmHg. Blood gas showed pH 7.17, HCO3- 13.2, glucose level 35 and ketones of 6 mmol/l. He was diagnosed with DKA precipitated by inadequate insulin administration and stump infection. He was commenced on fixed rate insulin infusion (FRII) and antibiotics. In total he received 1 litre of fluid. He continued his scheduled haemodialysis sessions.
Discussion: Currently there are no studies available which assess the treatment of DKA in dialysis-dependent patients. DKA is uncommon in these patients as ESRF leads to improved glycaemic control due to reduced kidney gluconeogenesis, less insulin clearance and improved insulin sensitivity. Anuric dialysis patients do not have glycosuria and osmotic diuresis, therefore they are less likely to be volume deplete and often have minimal symptoms. Cautious administration of fluid boluses with monitoring is recommended in the presence of intravascular volume depletion. Rarely, DKA can cause pulmonary oedema in these patients due to interstitial hypertonicity from hyperglycaemia, which often responds to insulin treatment alone. If there is inadequate response to maximal medical therapy, earlier haemodialysis is warranted.
Conclusion: Aggressive intravenous fluid resuscitation is a key treatment for DKA. However, cautious fluid administration should be considered in dialysis-dependent patients.
20 - 23 May 2017
European Society of Endocrinology