Abstract: SA-PO388
SGLT2 Inhibitors Are a New String for Nephrologists' Bow: Time to Be Excited yet Exercise Caution
Session Information
- Genetic and Diagnostic Trainee Case Reports
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 902 Fluid and Electrolytes: Clinical
Authors
- Yang, Ming-Jim Jimmy, University of Florida, Gainesville, Florida, United States
- De Jesus, Eddy J., University of Florida, Gainesville, Florida, United States
- Belal, Amer Ashaab, University of Florida, Gainesville, Florida, United States
- Koratala, Abhilash, University of Florida, Gainesville, Florida, United States
Introduction
Diabetic ketoacidosis (DKA) is traditionally defined as a triad of hyperglycemia, anion gap metabolic acidosis, and ketosis. On the other hand, Euglycemic DKA (EDKA), associated with blood glucose levels of <200 mg/dL is a relatively rare variant that is being recognized more in the setting of sodium glucose cotransporter 2 (SGLT2) inhibitors use. With the recent CREDENCE trial showing that Canagliflozin (a SGLT2 inhibitor) portends better renal and cardiovascular outcomes in patients with type 2 diabetes mellitus, nephrologists need to be aware of EDKA, especially in the setting of acute kidney injury (AKI), which itself can contribute to metabolic acidosis and pose diagnostic challenge.
Case Description
A 69-year-old woman with a history of diabetes mellitus type 2, gastroparesis, hypertension and coronary artery disease presented with abdominal pain, nausea and vomiting for 3 days. She was on metformin 1000 mg twice a day and empagliflozin 25mg daily for her diabetes. She was found to have AKI with a serum creatinine of 4 mg/dL (baseline ~0.8). Other laboratory data was significant for hyperkalemia with a serum potassium level of 6 mmol/L and anion gap metabolic acidosis with a serum bicarbonate 10 mmol/L. There was no significant hyperglycemia and the blood glucose level was 150 mg/dL. Lactic acid level was near-normal. Her urinalysis was positive for ketones and plasma beta hydroxybutyrate level was found to be elevated at 3 mmol/L. She was diagnosed with EDKA and treated with intravenous insulin and fluids. Her ketosis and renal failure resolved subsequently.
Discussion
Despite euglycemia, EDKA remains a medical emergency and must be diagnosed in a timely manner. As the use of SGLT2 inhibitors is likely to increase considerably in near future, nephrologists should have high index of suspicion for their adverse effects including but not limited to EDKA, urinary tract infections, renal tubular acidosis, lower-limb ulcerations etc. Serum ketones should be obtained in any patient with nausea, vomiting, or malaise while taking SGLT2 inhibitors, and the drug should be discontinued if acidosis is confirmed. Moreover, other causes of metabolic acidosis such as acute kidney injury, metformin-associated lactic acidosis, superimposed Fanconi syndrome from SGLT2 inhibitors should be considered in the differential diagnosis.