Can Diabetic Ketoacidosis (DKA) present with lactic acidosis?

Diabetic Ketoacidosis and Lactic Acidosis

Yes, diabetic ketoacidosis (DKA) can present with concurrent lactic acidosis, creating a mixed acid-base disturbance that complicates the clinical picture and management.

Pathophysiology of DKA and Lactic Acidosis Coexistence

• DKA is characterized by insulin deficiency and elevated counterregulatory hormones leading to hyperglycemia, ketosis, and metabolic acidosis 1
• While the primary acid-base disturbance in DKA is a high anion gap metabolic acidosis from ketone bodies (β-hydroxybutyrate and acetoacetate), lactic acidosis can occur simultaneously 1
• Lactic acidosis in DKA may result from tissue hypoperfusion due to dehydration, hypotension, and reduced peripheral perfusion 2, 3
• The differential diagnosis of high anion gap metabolic acidosis in DKA must include lactic acidosis as a potential contributor to the acidemia 1

Clinical Presentation and Diagnosis

• When evaluating a patient with suspected DKA, laboratory assessment should include:

  • Arterial blood gases to assess pH and bicarbonate levels 1
  • Serum electrolytes with calculated anion gap 1
  • Serum ketones and glucose 1
  • Lactate levels to identify concurrent lactic acidosis 2, 3

• Mixed acid-base disorders are common in DKA, with one study showing that traditional acidemic DKA (pH ≤ 7.3) accounts for only 48.9% of cases, while others present with mild acidemia or even alkalemia 4

Management Implications

• Treatment of DKA with concurrent lactic acidosis requires:

  • Aggressive fluid resuscitation with isotonic saline (15-20 ml/kg/h during the first hour) to restore circulatory volume and tissue perfusion 1
  • Insulin therapy to correct hyperglycemia and suppress ketogenesis 1
  • Monitoring of both ketones and lactate levels during treatment 2, 3
  • Identification and treatment of any underlying cause of lactic acidosis (e.g., sepsis, tissue hypoperfusion) 1

• Bicarbonate administration is generally not recommended in DKA management, even with severe acidosis, as studies have shown no difference in resolution of acidosis or time to discharge 1

Special Considerations

• Euglycemic DKA (serum glucose <250 mg/dL) can occur in approximately 10% of DKA cases and may be associated with SGLT2 inhibitor use, pregnancy, reduced food intake, alcohol use, or liver failure 1, 5

• Lactic acidosis may persist or even worsen during initial DKA treatment, particularly in patients with serious underlying disorders, and is associated with a poor prognosis 6

• Careful monitoring of acid-base status throughout treatment is essential as the ketoacidosis may resolve but be replaced by persistent lactic acidosis in some cases 3, 6

Clinical Pitfalls to Avoid

• Don't attribute all of the acidosis in DKA to ketones alone; consider measuring lactate levels to identify concurrent lactic acidosis 2, 3
• Don't miss euglycemic DKA due to relatively normal glucose levels (<250 mg/dL); check for ketones in patients with unexplained acidosis even without marked hyperglycemia 1, 5
• Don't overlook mixed acid-base disorders in DKA patients, as they can present with complex acid-base disturbances including concurrent metabolic alkalosis or respiratory disorders 4