From the Guidelines
Yes, it is possible to have diabetic ketoacidosis (DKA) with an alkalotic pH, though this is uncommon. This condition is known as "masked DKA" or "euglycemic DKA with alkalosis," and it is crucial to recognize it to prevent delayed diagnosis and treatment, which can significantly impact morbidity, mortality, and quality of life 1. The management goals for DKA, as outlined in the standards of care in diabetes-2024, include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis 1.
When evaluating patients with diabetes, it's essential to check for ketones and calculate the anion gap, even if the pH is not acidotic, especially if other signs of DKA such as hyperglycemia, dehydration, or nausea are present. The use of bicarbonate in people with DKA has been shown to make no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1. Treatment still follows standard DKA protocols with insulin, fluids, and electrolyte management, while also addressing the underlying cause of the alkalosis.
Key considerations in managing DKA include:
- Restoration of circulatory volume and tissue perfusion
- Resolution of ketoacidosis
- Correction of electrolyte imbalance and acidosis
- Treatment of any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke
- Administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
From the Research
Diabetic Ketoacidosis with Alkalotic pH
- Diabetic ketoacidosis (DKA) is commonly associated with metabolic acidosis, but it can also present with mixed acid-base disorders, including alkalosis 2.
- A study published in The Journal of Emergency Medicine found that 23.3% of DKA cases presented with an alkalotic pH (> 7.4), which is referred to as diabetic ketoalkalosis 2.
- Diabetic ketoalkalosis is characterized by the presence of increased anion gap metabolic acidosis, concurrent metabolic alkalosis, respiratory alkalosis, and/or respiratory acidosis 2.
- Another study published in Oxford Medical Case Reports described a case of DKA masked by both euglycemia and a primary metabolic alkalosis, highlighting the importance of considering DKA in diabetic patients with an anion gap and/or ketosis, even in the absence of hyperglycemia and acidemia 3.
- The traditional criteria for DKA diagnosis, which include pH ≤ 7.3 or bicarbonate ≤ 18 mmol/L, may not be sufficient to capture all cases of DKA, particularly those with mixed acid-base disorders 2, 4, 5.
Key Findings
- DKA can present with an alkalotic pH, which is often associated with mixed acid-base disorders 2, 3.
- Diabetic ketoalkalosis is a common yet easily overlooked variant of DKA that requires the same treatment as traditional DKA 2.
- The diagnosis of DKA should be considered in diabetic patients with an anion gap and/or ketosis, even in the absence of hyperglycemia and acidemia 3, 4, 5.