Kidney Week

Abstract: SA-PO507

Dapagliflozin-Associated Ketoacidosis in the Absence of Diabetes

Session Information

• Acid-Base, Calcium, Potassium, and Magnesium Disorders: Clinical
  October 26, 2024 | Location: Exhibit Hall, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Fluid, Electrolytes, and Acid-Base Disorders

• 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

• Dweik, Loai, Cleveland Clinic Akron General, Akron, Ohio, United States

Loai Dweik, MD

• Aleyadeh, Wesam, Cleveland Clinic Akron General, Akron, Ohio, United States

Wesam Aleyadeh, MD

• Rath, Pratik, Cleveland Clinic Akron General, Akron, Ohio, United States

Pratik Rath, MD

• Salih Bacha, Dania, Cleveland Clinic, Cleveland, Ohio, United States

Dania Salih Bacha, MD

• Tanphaichitr, Natthavat, Cleveland Clinic Akron General, Akron, Ohio, United States

Natthavat Tanphaichitr, MD

Introduction

Dapagliflozin is a sodium-glucose transport protein 2 (SGLT-2) inhibitor developed for diabetes management and has emerged as a therapeutic option for heart failure. Use of these agents in the perioperative period remains an area of concern, with growing reports of adverse events and perioperative complications. We describe a case that highlights the importance of management and monitoring of SGLT-2 inhibitors in non-diabetic patients during the perioperative period.

Case Description

A 71-year-old female with a history of hypertension, restless leg syndrome, and depression presented with left hemiparesis. Physical examination revealed normotension, left lower facial droop, left hemiparesis with left upper extremity strength 4/5, left lower extremity 3/5 and ataxia. Complete blood count and creatinine were within normal range. She was subsequently diagnosed with a right middle cerebral artery (MCA) infarct. She underwent cerebral angiogram with right MCA thrombectomy. Post-procedurally, she was found to have an elevated anion gap (19 mmol/L), low bicarbonate (14 mmol/L), and high beta hydroxybutyrate (>2.00 mmol/L). A venous blood gas showed acidemia with primary metabolic acidosis and respiratory compensation. Her hospital course was complicated by new onset atrial fibrillation and systolic dysfunction with findings of a low ejection fraction (35%) on echocardiogram and initiation of dapagliflozin for heart failure with reduced ejection fraction. Nephrology was consulted for progressively worsening serum bicarbonate. Workup showed normal renal function, absence of diabetes (HbA1c: 5.2%), unremarkable ethylene glycol, methanol, and salicylate levels.

Discussion

The patient's serum bicarbonate levels continued to downtrend with persistent acute high anion gap metabolic acidosis (HAGMA). The patient had no history of Type 1 diabetes making euglycemic diabetic ketoacidosis (DKA) unlikely. Suspicion fell on dapagliflozin, which had been prescribed shortly after admission and post-thrombectomy. It was subsequently discontinued with HAGMA resolution.Despite lacking a history of diabetes, the patient's prolonged fasting, surgical stress, and dapagliflozin use may have contributed to the observed metabolic disturbance. Clinicians must exercise caution when continuing SGLT-2 inhibitors during the perioperative period, even in non-diabetic heart failure patients.