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Abstract: SA-PO602

Dialysis in Diabetic Ketoacidosis (DKA)? Profound Acidemia in the Setting of Diabetic Ketoacidosis Triggered by Inferior ST-Elevation Myocardial Infarction (STEMI)

Session Information

Category: Dialysis

  • 801 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Barnes, Alex, Cleveland Clinic, Cleveland, Ohio, United States
  • Mehdi, Ali, Cleveland Clinic, Cleveland, Ohio, United States
  • Ferreira Provenzano, Laura, Cleveland Clinic, Cleveland, Ohio, United States
Introduction

Diabetic ketoacidosis (DKA) is a life-threatening condition that can cause severe acidemia impairing cardiac contractility and vascular tone. The role of bicarbonate therapy remains controversial. We present a case of severe DKA triggered by an myocardial infarction that required continuous venovenous hemodialysis(CVVHD) for severe acidemia.

Case Description

A 32 year old female with poorly controlled Type 1 Diabetes mellitus was brought to the ED unresponsive. Family reported preceding nausea, vomiting, and confusion after heavy alcohol use and skipping insulin. She was hemodynamically stable but obtunded with dry mucous membranes and Kussmaul respirations. VBG showed a pH<6.8, pCO2 16mmHg, bicarbonate<2mmol/L, potassium 6.7mmol/L and lactate 9.9mmol/L. Serum glucose was 1255mg/dL, BHB >4.5mmol/L, and creatinine 2.24mg/dL (baseline 0.7mg/dL). ECG revealed ST elevations in inferior leads. The patient received bicarbonate based crystalloids along with insulin. Two hours later, VBG showed persistent severe academia (pH 6.85) and a rising serum Troponin. Despite improving urine output, given severe acidemia, CVVHD was started (effluent dose: 30ml/kg/hr). The patient’s pH normalized and a left heart catheterization was done revealing an 80% thrombotic lesion in the RCA which was stented. Dialysis was continued for 8 hours with careful attention to potassium balance. Kidney function recovered with creatinine dropping to 1.01mg/dL after 24 hours. Overshoot alkalosis with mild alkalemia(pH 7.49) followed and was managed expectantly. Patient was discharged two days thereafter with appropriate follow-up.

Discussion

DKA is a life threatening condition triggered by infections, stroke, malignancy, myocardial infarction, or medical nonadherence. In addition to managing DKA, timely identification of the underlying trigger is critical to patient outcomes. The role of bicarbonate therapy in DKA is controversial and the role of renal replacement therapy in severe cases remains undefined. This case illustrates the use of bicarbonate based fluids and ultimately CVVHD successfully to control the patient’s severe metabolic derangement to expedite timely revascularization. Hourly assessments with careful attention to potassium balance and acid base status is critical to this strategy.