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Abstract: PO1173

CRRT-Associated Ketoacidosis: A Series of 5 Cases

Session Information

Category: Fluid, Electrolyte, and Acid-Base Disorders

  • 902 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

  • Parikh, Rushang, Icahn School of Medicine at Mount Sinai, New York, New York, United States
  • Khanin, Yuriy, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
  • Wanchoo, Rimda, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
  • Sharma, Purva D., Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
Introduction

Continuous renal replacement therapy (CRRT) is a dialysis modality used in critically ill patients with acute kidney injury (AKI). Although most dialysate and replacement fluids are dextrose-containing, CRRT-associated hypophosphatemia sometimes warrants the use of phosphorus containing solutions which are dextrose-free. As glucose is a small molecule which is readily cleared with dialysis, use of these solutions can result in increased dialysate caloric loss, net glucose deficit, and shifting of the metabolic pathway towards gluconeogenesis and ketogenesis. Starvation ketoacidosis can result, which at times can be severe.

Case Description

We describe five patients who developed worsening metabolic acidosis despite adequate clearance from CRRT, and were diagnosed with CRRT associated ketoacidosis( Figure 1 describes the clinical details, lab values and follow up of these patients) Administration of dextrose containing fluids or tube feeds promptly resulted in resolution of ketonemia and acidosis.

Discussion

These cases present an interplay of three processes ultimately culminating in a state of net glucose deficit: (1) decreased glucose supplementation in the critically ill patient, (2) increased clearance of glucose via CRRT with dextrose-free solutions and (3) AKI leading to deranged kidney gluconeogenesis.

New HAGMA in patients on CRRT in the ICU can frequently be attributed to inadequate CRRT dose. The reflex increase in dialysate or replacement fluid flow rate is associated with a slew of problems including electrolyte abnormalities, decreased effectiveness of antibiotics due to increased clearance all of which can be detrimental to the patient. A new consideration that must be made when utilizing dextrose free CRRT fluids is CRRT associated ketoacidosis. Early identification of this diagnosis is important and easily reversible.