Extreme hyperglycemia and diabetic ketoacidosis occurring in a patient on chronic dialysis

Department of Urology, North medical center, Kyoto prefectural university of medicine, Kyoto, Japan.Department of Nephrology and Urology, Nishijin Hospital, Kyoto, Japan.Department of Internal medicine, Nishijin Hospital, Kyoto, Japan.Diabetic ketoacidosis (DKA) is a complication that is rarely reported in patients on chronic dialysis. Herein, we describe the case of a patient on chronic hemodialysis who presented to us with acute onset diabetic ketoacidosis. A 50-year-old man with insulin-dependent diabetes mellitus, who was on hemodialysis for 2 years, presented to us with altered consciousness. Laboratory data revealed the following results: blood sugar, 110.1 mmol/L (1984 mg/dL); serum sodium, 107 mmol/L; β -hydroxybutyric acid, 1991 μ M; pH, 7.048. A diagnosis of diabetic ketoacidosis was made, and insulin therapy and hemodialysis were initiated, following which his parameters including blood glucose, and serum potassium and sodium improved. High osmotic dehydration was not observed in our patient owing to his renal dysfunction. The patient’s consciousness normalized following the correction of hyperglycemia and DKA. This case report highlights the importance of early diagnosis of DKA, and prompt initiation of insulin therapy and hemodialysis in patients on chronic dialysis. Therefore, in patients with end stage renal disease, the blood glucose correction should be followed by the restoration of sodium and osmolality, guided by corrected sodium concentration and effective osmolality, and by the appropriate adjustment of insulin and dialysis