How should I manage a patient with hyperglycemia (blood glucose 293 mg/dL), metabolic acidosis (serum CO₂ 20 mmol/L, anion gap 17 mmol/L), elevated BUN/creatinine ratio, reduced estimated glomerular filtration rate (eGFR 54 mL/min), markedly elevated creatine kinase (≈ 2 400 U/L), and leukocytosis (white blood cell count 18.8 ×10⁹/L)?

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Management of Hyperglycemic Crisis with Rhabdomyolysis and Acute Kidney Injury

This patient requires immediate intensive care management for diabetic ketoacidosis (DKA) with concurrent rhabdomyolysis and acute kidney injury, prioritizing aggressive fluid resuscitation, continuous intravenous insulin therapy, and close monitoring for complications including cerebral edema and electrolyte disturbances.

Clinical Assessment

Your patient presents with:

  • Hyperglycemic crisis: Blood glucose 293 mg/dL with metabolic acidosis (CO₂ 20 mmol/L, anion gap 17 mmol/L, beta-hydroxybutyrate 1.09 mmol/L)
  • Acute kidney injury: eGFR 54 mL/min, elevated BUN/creatinine ratio (28.1), suggesting prerenal azotemia from volume depletion
  • Rhabdomyolysis: CK 2,369 U/L (markedly elevated)
  • Systemic inflammatory response: WBC 18.77 × 10⁹/L

This constellation meets criteria for DKA (glucose >250 mg/dL, bicarbonate <18 mEq/L, anion gap >12, positive ketones) 1, 2. The elevated BUN/creatinine ratio and reduced eGFR indicate significant volume depletion, while the markedly elevated CK suggests rhabdomyolysis as a complication.

Immediate Management Protocol

1. Fluid Resuscitation (First Priority)

Start with isotonic saline (0.9% NaCl) at 15-20 mL/kg/h (1-1.5 liters) during the first hour 1. Given the elevated BUN/creatinine ratio and reduced eGFR, this patient has significant intravascular volume depletion requiring aggressive initial resuscitation.

  • After the first hour, switch to 0.45% NaCl at 4-14 mL/kg/h if corrected sodium is normal or elevated 1
  • Calculate corrected sodium: add 1.6 mEq for each 100 mg/dL glucose above 100 mg/dL 1, 3
  • Monitor hemodynamic status, urine output, and renal function closely to avoid fluid overload 1

Critical caveat: The rhabdomyolysis (CK 2,369 U/L) requires particularly aggressive hydration to prevent myoglobin-induced acute tubular necrosis. Maintain urine output >200 mL/hour initially.

2. Insulin Therapy

Before starting insulin, verify serum potassium is >3.3 mEq/L 1. If potassium is low, hold insulin and supplement potassium first to avoid life-threatening hypokalemia.

Once potassium is adequate:

  • IV bolus: 0.15 units/kg regular insulin 1
  • Continuous infusion: 0.1 units/kg/h (approximately 5-7 units/hour for average adult) 1
  • Target glucose decline of 50-75 mg/dL per hour 1
  • If glucose doesn't fall by 50 mg/dL in the first hour, double the insulin infusion rate hourly until achieving steady decline 1

When glucose reaches 250 mg/dL: Decrease insulin to 0.05-0.1 units/kg/h and add 5-10% dextrose to IV fluids 1. Continue insulin until anion gap closes and bicarbonate normalizes, not just until glucose normalizes.

3. Electrolyte Management

Potassium replacement is critical 1:

  • Once renal function is confirmed and potassium known, add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 1
  • Monitor potassium every 2-4 hours initially
  • Expect total body potassium deficit of 3-5 mEq/kg despite normal or elevated initial serum levels 1

Phosphate: The 1/3 KPO₄ supplementation addresses typical phosphate deficits of 5-7 mmol/kg 1

Magnesium: Monitor and replace as needed, particularly given the rhabdomyolysis

4. Monitoring Protocol

Laboratory monitoring every 2-4 hours 1:

  • Serum electrolytes (sodium, potassium, chloride, bicarbonate)
  • Glucose
  • BUN and creatinine (given AKI)
  • Venous pH and anion gap (arterial blood gases not necessary after initial assessment) 1
  • CK levels (for rhabdomyolysis monitoring)

Clinical monitoring:

  • Hourly vital signs and neurological status
  • Strict intake/output (target urine output >200 mL/hour given rhabdomyolysis)
  • Mental status changes (cerebral edema risk, though more common in pediatrics)

5. Identify and Treat Precipitating Factors

The leukocytosis (WBC 18.77) warrants investigation for infection 1, 2:

  • Obtain cultures (blood, urine, throat) if infection suspected 1
  • Chest X-ray if respiratory symptoms present 1
  • Start empiric antibiotics if sepsis suspected

Common DKA precipitants to consider:

  • Infection (most common)
  • Medication non-compliance
  • New-onset diabetes
  • Myocardial infarction or stroke (check ECG, troponin if indicated) 2

6. Special Considerations for This Patient

Rhabdomyolysis management:

  • The CK of 2,369 U/L requires aggressive hydration as outlined above
  • Monitor for compartment syndrome
  • Watch for hyperkalemia from muscle breakdown
  • Consider alkalinization of urine if pH remains low despite DKA treatment (controversial)

Acute kidney injury:

  • The elevated BUN/creatinine ratio (28.1) and reduced eGFR (54) suggest prerenal azotemia
  • Should improve with fluid resuscitation
  • If creatinine continues rising despite adequate hydration, consider nephrology consultation 4
  • Avoid nephrotoxic agents
  • Adjust medication doses for renal function

Hyperchloremic acidosis risk: Aggressive normal saline resuscitation can cause hyperchloremic metabolic acidosis 5. Monitor chloride levels and consider switching to balanced crystalloids if chloride rises significantly and anion gap closes but acidosis persists.

Resolution Criteria

DKA is resolved when ALL of the following are met 3:

  • Glucose <200 mg/dL
  • Serum bicarbonate ≥18 mEq/L
  • Venous pH >7.3
  • Anion gap normalized

Important: Beta-hydroxybutyrate clearance takes longer than glucose normalization. The nitroprusside method (urine ketones) may paradoxically worsen as beta-hydroxybutyrate converts to acetoacetate during treatment 1. Do not use urine ketones to guide therapy.

Transition to Subcutaneous Insulin

When DKA resolves and patient can eat:

  • Administer basal insulin (long-acting analog) 2-4 hours BEFORE stopping IV insulin 2, 6
  • This prevents rebound hyperglycemia and recurrent ketoacidosis
  • Start basal-bolus regimen with total daily dose of 0.3-0.5 units/kg 7

Critical Pitfalls to Avoid

  1. Starting insulin before checking potassium: Can precipitate fatal hypokalemia 1
  2. Stopping IV insulin when glucose normalizes: Leads to recurrent ketoacidosis; continue until anion gap closes 1
  3. Inadequate fluid resuscitation: Particularly dangerous with concurrent rhabdomyolysis and AKI
  4. Using bicarbonate therapy: Not recommended; no benefit shown and may worsen outcomes 2, 6
  5. Stopping IV insulin without overlap with subcutaneous basal insulin: Causes rebound hyperglycemia 2, 6
  6. Over-rapid correction of osmolality: Should not exceed 3 mOsm/kg/h to avoid cerebral edema 1

References

7
Guideline

management of diabetes and hyperglycaemia in the hospital.

The Lancet Diabetes and Endocrinology, 2021

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