Challenges in management of diabetic ketoacidosis in hemodialysis patients, case presentation and review of literature

Chronic kidney disease is associated with accumulation of uremic toxins that increases insulin resistance which will lead to blunted ability to suppress hepatic gluconeogenesis and reduce peripheral utilization of insulin. CKD patients fail to increase insulin secretion in response to insulin resistance because of acidosis, 1,25 vitamin D deficiency, and secondary hyperparathyroidism. Hemodialysis causes further fluctuations in glycemic control due to alterations in insulin secretion, clearance and resistance. DKA is uncommon in hemodialysis patients because of the absence of glycosuria and osmotic diuresis which accounts for most of the fluid and electrolyte losses seen in DKA, anuric patients may be somewhat protected from dehydration and shock, although still subject to hyperkalemia and metabolic acidosis. However, substantial volume loss can still occur due to a prolonged decrease in oral intake or increased insensible water losses related to tachypnoea and fever. There is no current guidelines for the management of diabetic ketoacidosis in anuric hemodialysis patients considering their differences than general population. In this review article we reviewed the literature and came with specific recommendations for management of Ketoacidosis in patients with CKD treated by hemodialysis. (C) 2019 Diabetes India. Published by Elsevier Ltd. All rights reserved.