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DIABETIC KETOALKALOSIS: A COMMON YET EASILY OVERLOOKED ALKALEMIC VARIANT OF DIABETIC KETOACIDOSIS ASSOCIATED WITH MIXED ACID-BASE DISORDERS

Published:December 29, 2022DOI:https://doi.org/10.1016/j.jemermed.2022.12.023

      Abstract

      Background

      Diabetic ketoacidosis (DKA) is commonly complicated by mixed acid-base disorders. Therefore, patients with DKA can present with pH > 7.3 or bicarbonate > 18 mmol/L, which falls outside the values defined by the current traditional DKA criteria (pH ≤ 7.3 or bicarbonate ≤ 18 mmol/L).

      Objective

      We aimed to study the spectrum of acid-base clinical presentations of DKA and the prevalence of diabetic ketoalkalosis.

      Methods

      This study included all adult patients at a single institution admitted in 2018–2020 with diabetes, positive beta-hydroxybutyric acid, and increased anion gap ≥ 16 mmol/L. Mixed acid-base disorders were analyzed to determine the spectrum of presentation of DKA.

      Results

      There were 259 encounters identified under the inclusion criteria. Acid-base analysis was available in 227 cases. Traditional acidemic DKA (pH ≤ 7.3), DKA with mild acidemia (7.3 < pH ≤ 7.4), and diabetic ketoalkalosis (pH > 7.4) account for 48.9% (111/227), 27.8% (63/227), and 23.3% (53/227) of cases, respectively. Of the 53 cases with diabetic ketoalkalosis, increased anion gap metabolic acidosis was present in all, and concurrent metabolic alkalosis, respiratory alkalosis, and respiratory acidosis were present in 47.2% (25/53), 81.1% (43/53), and 11.3% (6/53) encounters, respectively. In addition, 34.0% (18/53) of those with diabetic ketoalkalosis were found to have severe ketoacidosis, defined by beta-hydroxybutyric acid ≥ 3 mmol/L.

      Conclusions

      DKA can present as traditional acidemic DKA, DKA with mild acidemia, and diabetic ketoalkalosis. Diabetic ketoalkalosis is a common yet easily overlooked alkalemic variant of DKA associated with mixed acid-base disorders, and a high proportion of these presentations have severe ketoacidosis and thus, require the same treatment as traditional DKA.

      Keywords

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