Abstract: PUB179
An Underrecognized Cause of Unexplained High Anion Gap Metabolic Acidosis on Continuous Kidney Replacement Therapy: A Case Series of Euglycemic Ketoacidosis
Session Information
Category: Dialysis
- 801 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Aung, Htun Min, New York City Health and Hospitals Jacobi, Bronx, New York, United States
- Thida, Aye Mon, SUNY Downstate Health Sciences University, Brooklyn, New York, United States
- Acharya, Anjali, New York City Health and Hospitals Jacobi, Bronx, New York, United States
Introduction
Euglycemic ketoacidosis (EKA) on continuous renal replacement therapy (CRRT) first appeared in the literature in 2018 after Coutrot et al. described 18 patients (15%) who developed EKA on CRRT using a glucose-free solution. Subsequently, in 2020, Sriperumbuduri et al. proposed pathophysiologic mechanisms of EKA on CRRT as 1) glucose losses from CRRT with glucose-free solutions; 2) compromised caloric intake; and 3) stress of critical illness. These conditions create a state of low-insulin, high-glucagon levels, leading to increased lipolysis and ketogenesis causing ketoacidosis, while on the other hand, causing increased glycogenolysis and gluconeogenesis to maintain euglycemia. However, the EKA on CRRT is still under-recognized at the provider level.
Case Description
We present the clinical characteristics of 3 patients who developed euglycemic ketoacidosis on continuous renal replacement therapy (Table 1).
Case 1: A 79-year-old female had a history of chronic kidney disease (CKD) stage 3A, hypertension (HTN), diabetes mellitus type 2 (DM-2), and heart failure with reduced ejection fraction (HFrEF).
Case 2: An 82-year-old male had a history of CKD stage 2, HTN, DM-2, adenocarcinoma of colon, and HFrEF.
Case 3: A 73-year-old male had a history of CKD stage 5, HTN, DM-2, and HFrEF.
Discussion
Providers should consider EKA as one of the differential diagnoses of high anion-gap metabolic acidosis when evaluating a patient on CRRT, especially using a glucose-free solution. The beta-hydroxybutyrate test is easily available in most laboratories, and once the diagnosis of EKA is made, management is feasible and could potentially avoid catastrophic complications.