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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Article info
Publication history
Published online: December 29, 2022
Accepted:
December 13,
2022
Received in revised form:
November 21,
2022
Received:
September 9,
2022
Publication stage
In Press Uncorrected ProofIdentification
Copyright
© 2022 Elsevier Inc. All rights reserved.
