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Abstract: SA-PO442

Euglycemic Ketoacidosis: An Underrecognized Complication of Continuous Renal Replacement Therapy

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Adewuyi, Joel O., University of Florida, Gainesville, Florida, United States
  • Choi, Jusong, University of Florida, Gainesville, Florida, United States
  • Kazory, Amir, University of Florida, Gainesville, Florida, United States

Euglycemic Ketoacidosis (EKA) is a rare presentation of diabetic ketoacidosis in patients with reduced caloric intake and those using newer antidiabetic medications. It is also seen in other settings where the body has to go to a ketogenic state due to reduced available glucose.

Case Description

A 52-year-old woman with a history of hypertension and diabetes was admitted for necrotizing soft tissue infection of the lower extremity. Hospital course was complicated by septic shock and oliguric acute kidney injury. Continuous renal replacement therapy (CRRT) was started with a conventional solution leading to gradual improvement in patient’s biochemical profile (Day 0). Nutrition was provided with low-glycemic carbohydrate along with intravenous insulin infusion. Two days later, CRRT solution was changed to a phosphate-containing solution to reduce the need for phosphate supplementation. This was followed by an unexplained progressive drop in serum bicarbonate levels in the face of normal serum lactate levels (anion gap metabolic acidosis [AGMA]) (Day 2). Since the phosphate-containing solution is glucose-free, there was a suspicion for development of ketosis; serum beta hydroxybutyrate was found to be as high as as 6.6 mmol/L (normal: ≤0.27) with stable glycemia confirming the diagnosis of EKA. CRRT solution was changed back to a conventional glucose-containing solution leading to a gradual reduction in the level of ketones and normalization of serum bicarbonate concentrations (Day 4).


Since most patients on CRRT are critically ill and several of their biochemical parameters not within the normal range, EKA may remain unrecognized unless patients are screened for it. The diagnosis should be considered once there is progressive AGMA despite ongoing CRRT, in the absence of lactic acidosis, especially if a glucose-free solution is used.