Diabetic Ketoacidosis (DKA) with Hematuria and Proteinuria
Primary Diagnosis
This 25-year-old female is presenting with diabetic ketoacidosis (DKA), evidenced by the urinalysis showing >2000 mg/dL glucose and large ketones. The upper GI discomfort (nausea, vomiting, abdominal pain) is a classic presenting symptom of DKA, not a primary gastrointestinal disorder 1, 2. The large blood and protein on urinalysis require investigation but should not delay immediate DKA management.
Immediate Diagnostic Workup
Obtain the following laboratory tests immediately 3, 4:
- Arterial or venous blood gas for pH assessment (DKA diagnosis requires pH <7.3)
- Complete metabolic panel including electrolytes, BUN, creatinine
- Serum ketones (β-hydroxybutyrate preferred over nitroprusside method)
- Calculated anion gap (DKA requires >10-12 mEq/L)
- Serum osmolality
- Complete blood count with differential
- Electrocardiogram with continuous cardiac monitoring
- Blood and urine cultures if infection suspected as precipitant
The hematuria and proteinuria warrant additional evaluation once DKA is stabilized, as these may represent diabetic nephropathy, urinary tract infection, or unrelated renal pathology 1.
Immediate Management Protocol
Fluid Resuscitation
Begin with balanced electrolyte solutions or 0.9% normal saline at 15-20 mL/kg/hour (approximately 1-1.5 L in the first hour) to restore circulatory volume and tissue perfusion 3, 4. Continue fluid replacement to correct estimated deficits within 24 hours, ensuring serum osmolality changes do not exceed 3 mOsm/kg/hour 3.
Insulin Therapy
Administer continuous intravenous regular insulin at 0.1 units/kg/hour without an initial bolus 3, 4. The American Diabetes Association now recommends omitting the initial bolus in most cases 3.
Critical monitoring points 1, 3:
- Check blood glucose every 1-2 hours
- If glucose does not fall by 50 mg/dL in the first hour, double the insulin infusion hourly until achieving a steady decline of 50-75 mg/dL per hour
- When glucose reaches 200-250 mg/dL, add dextrose-containing fluids (D5W or D10W) to maintain glucose 100-180 mg/dL while continuing insulin to clear ketosis 1, 3
Do not stop insulin when glucose normalizes—ketone clearance takes longer than glucose correction 1, 4.
Electrolyte Management
Potassium replacement is critical 3, 4:
- If initial potassium <3.3 mEq/L, delay insulin until potassium is restored to prevent life-threatening arrhythmias, cardiac arrest, and respiratory muscle weakness 3, 4
- Once potassium falls below 5.5 mEq/L (assuming adequate urine output), add 20-40 mEq/L potassium to infusion fluids 3
- Use 2/3 KCl and 1/3 KPO4 to maintain serum potassium 4-5 mEq/L 3
Bicarbonate therapy is NOT recommended—multiple studies show no benefit in resolution of acidosis or time to discharge 1, 3, 4.
Monitoring Parameters
Draw blood every 2-4 hours for serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 1, 3. Venous pH (typically 0.03 units lower than arterial pH) and anion gap can be followed to monitor resolution 3.
DKA Resolution Criteria
DKA is resolved when ALL of the following are achieved 3, 5:
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
- Anion gap ≤12 mEq/L
Transition to Subcutaneous Insulin
Administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1, 3, 4. This timing is critical and non-negotiable.
For newly diagnosed patients, initiate a multidose regimen of short- and intermediate/long-acting insulin at approximately 0.5-1.0 units/kg/day 3.
Identifying Precipitating Causes
Search for underlying triggers 1, 4:
- Infection (most common precipitant)—obtain cultures and start empiric antibiotics if suspected
- New-onset diabetes (25-30% of type 1 diabetes presents with DKA) 6
- Insulin omission or inadequate dosing
- Myocardial infarction or stroke
- SGLT2 inhibitor use (can cause euglycemic DKA)—discontinue if present 3, 5
Addressing the Hematuria and Proteinuria
Once DKA is stabilized, investigate the urinary findings:
- Repeat urinalysis after metabolic correction (some hematuria/proteinuria may be transient from severe hyperglycemia and dehydration)
- Urine microscopy to differentiate glomerular from non-glomerular hematuria
- Urine culture to exclude urinary tract infection
- Consider renal ultrasound if findings persist
- Evaluate for diabetic nephropathy with urine albumin-to-creatinine ratio once stable
Critical Pitfalls to Avoid
Do not stop IV insulin when glucose normalizes—continue until ketoacidosis resolves (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L) 1, 3.
Do not give insulin if potassium <3.3 mEq/L—this can cause fatal arrhythmias 3, 4.
Do not forget basal insulin 2-4 hours before stopping IV insulin—this prevents rebound hyperglycemia and recurrent DKA 1, 3.
Monitor for cerebral edema (rare but fatal complication)—avoid overly rapid correction of osmolality (maximum 3 mOsm/kg/hour) 1, 3.
Disposition and Prevention
Admit to intensive care unit for continuous monitoring given the severity of presentation 1.
Discharge planning must include 3, 4:
- Identification of outpatient diabetes care provider
- Education on DKA recognition, prevention, and sick-day management
- Insulin administration technique verification
- Follow-up within 1-2 weeks
- Emphasis on never discontinuing insulin, even during illness 1