Is a patient with ESRD on hemodialysis and severe hyperglycemia likely in DKA?

Diagnosing DKA in ESRD Patients on Hemodialysis

DKA can and does occur in ESRD patients on hemodialysis, but the diagnosis requires modified criteria because these patients cannot develop the typical severe dehydration, osmotic diuresis, or volume depletion that characterizes DKA in patients with normal kidney function. 1, 2

Key Diagnostic Criteria for DKA in ESRD Patients

Modified Triad for ESRD Patients

The diagnosis of DKA in hemodialysis patients requires:

• Hyperglycemia (typically >250 mg/dL, though ESRD patients often present with much higher glucose levels, averaging 804 mg/dL vs 472 mg/dL in those with normal renal function) 1
• Metabolic acidosis (low serum bicarbonate and low pH) 3, 1
• Ketonemia or ketonuria (elevated beta-hydroxybutyrate or positive urine/serum ketones) 2

Critical Differences from Standard DKA Presentation

ESRD patients with DKA present differently because they lack glycosuria and osmotic diuresis due to anuria, which somewhat protects them from the severe dehydration and shock typical of DKA. 2 However, they remain vulnerable to:

• Severe hyperkalemia (can reach extreme levels like 9.0 mEq/L due to absolute insulin deficit shifting potassium extracellularly combined with inability to excrete potassium renally) 3
• Metabolic acidosis (from ketone accumulation) 3, 2
• Volume overload (28% develop this during treatment vs only 3% in patients with normal renal function, because they cannot excrete the fluids typically given for DKA) 1

Specific Laboratory Findings to Confirm DKA in ESRD

Essential Tests

• Serum glucose: Expect markedly elevated levels (mean 804 mg/dL in ESRD vs 472 mg/dL in preserved renal function) 1
• Arterial or venous blood gas: Look for metabolic acidosis with low pH and low bicarbonate 3, 2
• Serum beta-hydroxybutyrate or urine/serum ketones: Confirms ketoacidosis 2
• Serum potassium: May be dangerously elevated despite total body potassium depletion 3
• ECG: Check for hyperkalemia changes (absent P waves, prolonged QRS, tented T waves) 3

Misleading Markers in ESRD

• HbA1c is falsely low in ESRD patients (mean 9.6% in ESRD vs 12.0% in preserved renal function despite worse acute hyperglycemia) due to anemia, erythropoietin use, reduced red blood cell lifespan, and frequent transfusions 4, 1
• Absence of severe dehydration does not rule out DKA in anuric patients 2
• Normal or elevated blood pressure does not exclude DKA since these patients lack the osmotic diuresis-induced volume depletion 2

Clinical Presentation Clues

Symptoms Suggesting DKA in ESRD

• Drowsiness, flushed face, fruity breath odor, loss of appetite (classic DKA symptoms that develop gradually over hours to days) 5
• Heavy breathing and rapid pulse (more severe symptoms) 5
• Nausea, vomiting, abdominal pain (late symptoms) 5
• History of insulin pump malfunction or insulin omission (common precipitant in ESRD patients with type 1 diabetes) 3

Red Flags Specific to ESRD

• Recent missed dialysis sessions or inadequate dialysis 2
• Infection, fever, or other acute stressors 5, 2
• Inability to manage insulin regimen (due to cognitive impairment, stroke, or other disability) 3

Critical Pitfalls to Avoid

Do not assume ESRD patients cannot develop DKA simply because they are anuric—they absolutely can develop ketoacidosis, though the presentation differs from standard DKA. 3, 1, 2 The absence of glycosuria protects against severe volume depletion but does not prevent ketone accumulation or metabolic acidosis. 2

Do not rely on physical examination findings of dehydration to diagnose or exclude DKA in ESRD patients, as they may have normal or even elevated volume status despite being in ketoacidosis. 2

Do not use glucose meters with glucose dehydrogenase-pyrroloquinoline quinone (GDH-PQQ) or glucose oxidase (GO) methodology in peritoneal dialysis patients, as these produce falsely elevated readings with icodextrin-containing solutions. 4, 6 Use hexokinase (HK), GDH-NAD, or GDH-FAD-based meters instead. 4

Algorithmic Approach to Diagnosis

Step 1: Measure Core Parameters

• Serum glucose (expect >250 mg/dL, often much higher) 1
• Arterial or venous pH and bicarbonate 3, 2
• Serum or urine ketones (or beta-hydroxybutyrate) 2

Step 2: Assess for ESRD-Specific Complications

• Serum potassium and ECG (check for life-threatening hyperkalemia) 3
• Volume status (assess for overload rather than depletion) 1

Step 3: Identify Precipitating Factors

• Review insulin administration history (pump malfunction, missed doses) 3
• Screen for infection, acute illness, or recent dialysis adequacy 2

If all three core parameters are abnormal (hyperglycemia, acidosis, ketones), the diagnosis is DKA regardless of volume status or HbA1c level. 1, 2