How do you treat Diabetic Ketoacidosis (DKA) in patients undergoing Hemodialysis (HD)?

Management of Diabetic Ketoacidosis in Hemodialysis Patients

For patients on hemodialysis with DKA, modify standard DKA protocols by using continuous intravenous insulin without an initial bolus, carefully monitoring electrolytes, and avoiding aggressive fluid resuscitation to prevent volume overload. 1

Initial Assessment and Diagnosis

• Perform comprehensive laboratory evaluation including plasma glucose, serum ketones (preferably direct measurement of β-hydroxybutyrate), electrolytes, arterial blood gases, complete blood count, and electrocardiogram 1, 2
• Evaluate for underlying causes of DKA such as infection, medication non-adherence, or stroke, which is crucial in hemodialysis patients 1
• Obtain bacterial cultures and chest X-ray if infection is suspected 1, 3

Modified Fluid Management for Hemodialysis Patients

• Administer fluid cautiously to avoid volume overload, unlike standard DKA protocols that recommend aggressive fluid resuscitation 1
• Monitor cardiac and respiratory status closely during fluid administration, assessing for signs of volume overload including respiratory distress, jugular venous distention, and peripheral edema 1
• Consider urgent hemodialysis if severe volume overload or extreme hyperkalemia is present 4

Insulin Therapy

• Initiate continuous intravenous regular insulin at 0.1 units/kg/hour without an initial bolus to prevent rapid shifts in potassium 1
• Continue insulin therapy until resolution of ketoacidosis, regardless of glucose levels 1, 2
• Add dextrose 5% to intravenous fluids when serum glucose reaches 250 mg/dL while continuing insulin infusion 1, 2
• Target glucose between 150-200 mg/dL until DKA resolution parameters are met 1

Electrolyte Management

• Check electrolytes every 2-4 hours until stable, with particular attention to potassium levels 1, 2
• Be vigilant for extreme hyperkalemia, which can occur in hemodialysis patients with DKA due to anuria and insulin deficiency 4
• Consider delaying insulin administration and first administering potassium chloride intravenously if plasma potassium level is low 5
• Consider urgent hemodialysis for severe hyperkalemia rather than aggressive fluid administration 4

Monitoring During Treatment

• Check blood glucose hourly and electrolytes every 2-4 hours 1, 2
• Monitor venous pH and anion gap to assess resolution of acidosis 1, 2
• Follow DKA resolution parameters: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 2
• Continue monitoring for at least 24 hours after resolution of DKA 1

Transition to Subcutaneous Insulin

• Transition to a multiple-dose insulin regimen when DKA resolves and the patient can eat 1, 2
• Administer basal insulin 2-4 hours before stopping the IV insulin infusion to prevent recurrence of ketoacidosis 1, 2

Special Considerations for Hemodialysis Patients

• Recognize that DKA in hemodialysis patients may present differently due to absence of glycosuria and osmotic diuresis 6
• Be aware that despite anuria, substantial volume loss can still occur due to decreased oral intake or increased insensible water losses 6
• Consider that hemodialysis itself causes fluctuations in glycemic control due to alterations in insulin secretion, clearance, and resistance 6
• Understand that hemodialysis patients may develop extreme hyperkalemia during DKA due to anuria and insulin deficiency 4

Discharge Planning

• Develop a structured discharge plan tailored to the individual patient 1
• Schedule follow-up appointments with both endocrinology and nephrology prior to discharge 1
• Ensure medication reconciliation with cross-checking of home and hospital medications 1
• Transmit discharge summaries to the primary care clinician and nephrologist promptly 1