Discharge Management After Resolved DKA
Check glucose-6-phosphate dehydrogenase (G6PD) enzyme deficiency in two to three months (Option B).
This patient presents with laboratory findings highly suggestive of hemolytic anemia occurring during DKA treatment: elevated reticulocyte count (4.5%), elevated indirect bilirubin (4.0 mg/dL), elevated LDH (550 U/L), mild anemia (Hgb 12.3 g/dL), and pallor with jaundice—all in the absence of schistocytes, spherocytes, or positive direct antiglobulin test. This constellation strongly indicates non-immune hemolysis, and G6PD deficiency is a well-recognized cause of oxidative hemolysis triggered by metabolic stress from DKA.
Why G6PD Testing Must Be Delayed
The critical pitfall is testing G6PD levels during or immediately after a hemolytic episode. During active hemolysis, older G6PD-deficient red blood cells are destroyed preferentially, leaving behind younger reticulocytes with relatively higher enzyme activity. This creates a false-negative result, missing the diagnosis entirely. Testing must be delayed 2-3 months after the hemolytic episode resolves to allow the red cell population to normalize and reveal the true enzyme deficiency.
Why Other Options Are Incorrect
Option A (No Additional Testing)
The laboratory evidence of hemolysis cannot be ignored. Elevated reticulocytes (4.5% vs normal <2%), elevated indirect bilirubin (4.0 mg/dL), and elevated LDH (550 U/L) with jaundice and pallor represent clear evidence of a hemolytic process that requires investigation. Missing G6PD deficiency puts the patient at risk for future severe hemolytic crises with oxidative stressors (infections, certain medications, fava beans).
Option C (Vitamin B12 Level)
The blood smear explicitly shows no macrocytosis and no hypersegmented neutrophils, ruling out megaloblastic anemia. The MCV is normal (89.5 fL). The elevated reticulocyte count indicates appropriate bone marrow response to hemolysis, not B12 deficiency.
Option D (Hemoglobin Electrophoresis)
The blood smear shows no target cells, no sickle cells, and no other morphologic features of hemoglobinopathy. The clinical picture of acute hemolysis triggered by metabolic stress (DKA) points to an enzymatic defect, not a structural hemoglobin disorder.
Option E (Bone Marrow Biopsy)
The elevated reticulocyte count (4.5%) demonstrates that the bone marrow is functioning appropriately and responding to hemolysis. There is no evidence of bone marrow failure (normal WBC, normal platelets, appropriate reticulocytosis). Bone marrow biopsy is invasive and unnecessary when peripheral blood findings clearly indicate hemolysis with adequate marrow response.
Standard DKA Discharge Requirements
While addressing the hemolysis question, standard discharge planning after DKA resolution must include 1:
- Structured discharge plan with scheduled follow-up appointments made prior to discharge 1
- Diabetes survival skills education covering insulin administration, glucose monitoring, hypoglycemia recognition/treatment, sick-day management, and proper needle disposal 1
- Medication reconciliation ensuring the patient has insulin supplies (vials or pens), syringes/pen needles, blood glucose meter and strips, lancets, and urine ketone strips 1
- Identification of outpatient provider for diabetes care after discharge 1
- Prevention education focusing on adherence to insulin therapy and early recognition of hyperglycemia to prevent DKA recurrence 2, 3
The patient's DKA was precipitated by missed insulin doses, making adherence education particularly critical 2, 3.
Clinical Reasoning Summary
The combination of hemolytic markers (elevated reticulocytes, indirect bilirubin, LDH) with jaundice and pallor, occurring in the context of DKA metabolic stress, without evidence of immune hemolysis (negative DAT) or structural RBC abnormalities (normal blood smear), makes G6PD deficiency the most likely diagnosis. However, immediate testing would be falsely reassuring due to the reticulocytosis. Delaying G6PD testing for 2-3 months is the only way to accurately diagnose this potentially life-threatening condition and prevent future hemolytic crises.