Hyperosmolar diabetic ketoacidosis-review of literature and the shifting paradigm in evaluation and management

Background: Hyperosmolar diabetic ketoacidosis (H-DKA), a distinct clinical entity, is the overlap of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Aim: We describe the clinical presentation, metabolic aberrations, and associated morbidity/mortality of these cases with H-DKA. We highlight the problem areas of medical care which require particular attention when caring for pediatric diabetes patients presenting with H-DKA. Methods: In our study we reviewed the literature back to 1963 and retrieved twenty-four cases meeting the criteria of H-DKA: glucose >600 mg/dL, pH < 7.3, bicarbonate <15 mEq/L, and serum osmolality >320 mOsm/kg, while adding three cases from our institution. Results: Average age of presentation of H-DKA was 10.2 years +/- 4.5 years in females and 13.3 years +/- 4 years in males, HbA1c was 13%. Biochemical parameters were consistent with severe dehydration: serum osmolality = 394.8 +/- 55 mOsm/kg, BUN = 48 +/- 22 mg/dL, creatinine = 2.81 +/- 1.03 mg/dL. Acute kidney injury, present in 12 cases, was the most frequent end-organ complication. Conclusion: Multi-organ involvement with AKI, rhabdomyolysis, pancreatitis, neurological and cardiac issues such as arrhythmias, are common in H-DKA. Aggressive fluid management, insulin therapy and supportive care can prevent acute and long term adverse outcomes in children and adolescents. (C) 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.

Automated summary

H-DKA is a distinct clinical entity that overlaps with DKA and HHS. Patients with H-DKA present at an average age of 10-13 years, with severe dehydration and renal complications being common features.