How can a patient with Diabetic Ketoacidosis (DKA) present with a normal pH level?

From the Guidelines

A patient with Diabetic Ketoacidosis (DKA) can present with a normal pH level in cases of mixed acid-base disorders, particularly when metabolic acidosis is counterbalanced by respiratory alkalosis or metabolic alkalosis. This phenomenon, sometimes called "euglycemic DKA," occurs when compensatory mechanisms temporarily normalize the pH despite ongoing ketoacidosis. Common scenarios include concurrent vomiting (causing loss of acid and metabolic alkalosis), respiratory compensation with hyperventilation (creating respiratory alkalosis), or use of sodium bicarbonate prior to evaluation. Certain medications like SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) can also cause DKA with near-normal glucose levels and potentially less severe pH disturbances. Despite a normal pH, other diagnostic criteria for DKA would still be present, including elevated anion gap, positive serum/urine ketones, and hyperglycemia (though sometimes only mild) 1. It's crucial to recognize that a normal pH doesn't exclude DKA, and clinicians should evaluate the complete clinical picture including symptoms, ketone levels, and anion gap when assessing patients with diabetes, especially those taking SGLT2 inhibitors or presenting with vomiting.

Some key points to consider in the management of DKA include:

• Restoration of circulatory volume and tissue perfusion
• Resolution of hyperglycemia
• Correction of electrolyte imbalance and acidosis
• Treatment of any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke
• Use of continuous intravenous insulin in critically ill and mentally obtunded individuals with DKA or hyperosmolar hyperglycemia
• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.

It's also important to note that the use of bicarbonate in patients with DKA made no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1. For further treatment information, refer to recent in-depth reviews.

Key diagnostic criteria for DKA include:

• Blood glucose 250 mg/dl
• Venous pH 7.3
• Bicarbonate 15 mEq/l
• Moderate ketonuria or ketonemia 1
• Elevated anion gap
• Positive serum/urine ketones
• Hyperglycemia (though sometimes only mild)

In summary, DKA can present with a normal pH level, and clinicians should be aware of this possibility and evaluate the complete clinical picture to make an accurate diagnosis.

From the Research

Presentation of Diabetic Ketoacidosis (DKA) with Normal pH

• DKA is a serious complication of diabetes that can present with a range of acid-base disturbances, including metabolic acidosis, metabolic alkalosis, and mixed acid-base disorders 2.
• While DKA is typically characterized by metabolic acidosis, some patients can present with a normal or even alkalotic pH, a condition known as diabetic ketoalkalosis 2.
• Diabetic ketoalkalosis is a common yet easily overlooked variant of DKA, accounting for approximately 23% of cases in one study 2.
• Patients with diabetic ketoalkalosis often have mixed acid-base disorders, with concurrent metabolic acidosis, metabolic alkalosis, and respiratory alkalosis or acidosis 2.

Mechanisms and Treatment

• The pathogenesis of DKA involves a complex interplay of factors, including insulin deficiency, increased counterregulatory hormones, and renal and electrolyte disturbances 3, 4.
• Treatment of DKA typically involves fluid replacement, insulin therapy, and electrolyte supplementation, with the goal of restoring optimal volume status, reversing acidosis, and reducing serum glucose levels 3, 4, 5.
• In patients with diabetic ketoalkalosis, treatment should focus on addressing the underlying metabolic acidosis and mixed acid-base disorders, rather than solely targeting the alkalotic pH 2.
• The use of sodium bicarbonate in DKA treatment is controversial and should be individualized, with consideration given to the patient's acid-base status, hemodynamic stability, and risk of complications 3, 5.

Clinical Implications

• Recognition of diabetic ketoalkalosis as a variant of DKA is crucial for optimal management and treatment 2.
• Clinicians should be aware of the potential for mixed acid-base disorders in patients with DKA and tailor treatment accordingly 2, 6.
• Further research is needed to fully understand the pathogenesis and treatment of diabetic ketoalkalosis, as well as the optimal management strategies for patients with DKA and mixed acid-base disorders 2.