Biochemical Parameters of Diabetes Ketoacidosis in Patients with End-stage Kidney Disease and Preserved Renal Function

Introduction: Differences in biochemical parameters of diabetic ketoacidosis in patients with end-stage kidney disease (ESKD) has not been established. Accordingly, we assessed the relationship between degree of metabolic acidosis and beta-hydroxybutyrate in patients with ESKD (eGFR < 15 mL/min/1.73 m(2)), moderate renal failure (eGFR 15-60), or preserved renal function (eGFR > 60). Methods: This observational study included adults (18-80 years) with diabetes ketoacidosis (DKA), admitted to Emory University Hospitals between January 1, 2006 to December 31, 2016. DKA and renal stages were confirmed on admission laboratory values. Results: Admission bicarbonate levels (13.9 5 vs 13.4 +/- 5.3 vs 13.8 +/- 4.2 mmol/L, P = 0.7), and pH levels (7.2 +/- 0.3 vs 7.2 +/- 0.2 vs 7.2 +/- 0.2, P = 0.8) were similar among groups. Patients with ESKD had lower mean beta-hydroxybutyrate level (4.3 +/- 3.3 vs 5.6 +/- 2.9 vs 5.9 +/- 2.5 mmol/L, P = 0.01), but higher admission glucose (852 +/- 340.4 vs 714.6 +/- 253.3 mg/dL vs 518 +/- 185.7 mg/dL, P < 0.01), anion gap (23.4 +/- 7.6 vs 23 +/- 6.9 vs 19.5 +/- 4.7 mmol/L, P < 0.01), and osmolality (306 +/- 20.6 vs 303.5 +/- vs 293.1 +/- 3.1mOsm/kg, P < 0.01) compared with patients with moderate renal failure and preserved renal function, respectively. The sensitivity of beta-hydroxybutyrate > 3 mmol/L for diagnosing DKA by bicarbonate level < 15 and <18 mmol/L was 86.9% and 72% in ESKD, 89.3% and 83.7% in moderate renal failure, and 96.2% and 88.3% in preserved renal function. In patients with ESKD, the corresponding beta-hydroxybutyrate with bicarbonate levels < 10, 10-15, <18 mmol/L were 5.5, 3.9, 3.0 mmol/L, respectively. Conclusions: Significant metabolic differences were found among DKA patients with different levels of renal function. In patients with ESKD, a beta-hydroxybutyrate level > 3 mmol/L may assist with confirmation of DKA diagnosis.

Automated summary

This study revealed significant metabolic differences among DKA patients with different levels of renal function, with beta-hydroxybutyrate levels potentially assisting in confirming the diagnosis of DKA in ESKD patients.