Diabetic Ketoacidosis/Hyperosmolar Coma in ESRD • Clinical Picture of hyperglycemia is modified (due to absence of renal function). o The absence of polyuria and glycosuria “safety valve” severe hyperglycemia (serum glucose level >1,000 mg/dL) o Alteration of mental status is unusual (Due to absence of water loss induced by osmotic diuresis). o Asymptomatic mostly in spite of severe hyperglycemia o Thirst, weight gain, and may be pulmonary edema or coma o Severe hyperkalemia in DKA in insulin-dependent dialysis patients. • Diagnosis in the ESKD patient is based on hyperglycemia, positive serum ketones, metabolic acidemia, and an increased anion gap. o Which is not easy due to the plasma reaction for ketones may be negative, the anion gap may not be affected and the clinical presentation itself of severe hyperglycemia and ketoacidosis are atypical. • Management of hyperglycemia with or without ketoacidosis differs from that in patients without renal failure in that administration of large amounts of fluid is unnecessary and generally contraindicated. o Insulin is the only treatment needed  can correct all clinical and laboratory abnormalities of hyperglycemia. o Can administer a continuous infusion of low-dose regular insulin (starting at 2 units/hr) with close clinical monitoring and measurement of serum glucose and potassium concentrations at 2- to 3-hour intervals. o Urgent dialysis if pulmonary edema and hyperkalemia. • IV bicarbonate is not indicated may exacerbate volume overload. • No phosphate replacement is generally needed. • Hypophosphatemia is not expected. • Magnesium deficiency is absent.

2.  Clinical Picture of hyperglycemia is modified (due to absence of
renal function).
 The absence of polyuria and glycosuria “safety valve” severe
hyperglycemia (serum glucose level >1000 mg/dL)
 Alteration of mental status is unusual (Due to absence of water
loss induced by osmotic diuresis).
 Asymptomatic mostly in spite of severe hyperglycemia
 Thirst, weight gain, and may be pulmonary edema or coma
 Severe hyperkalemia in DKA in insulin-dependent dialysis patients.

3.  Diagnosis in the ESKD patient is based on
hyperglycemia, +ve serum ketones, metabolic
acidemia with increased anion gap.
 Which is not easy due to the plasma reaction for
ketones may be negative, the anion gap may not be
affected and the clinical presentation itself of severe
hyperglycemia and ketoacidosis are atypical.

4.  Management of hyperglycemia with or without ketoacidosis differs
from that in patients without renal failure in that administration of
large amounts of fluid is unnecessary and generally contraindicated.
o Insulin is only treatment  can correct all clinical and laboratory
abnormalities of hyperglycemia.
o Can administer a continuous infusion of low-dose regular insulin
(starting at 2 units/hr) with close clinical monitoring and
measurement of serum glucose and potassium concentrations at 2-
to 3-hour intervals.

5. NB;
• IV bicarbonate is not indicated  may exacerbate
volume overload.
• Hypophosphatemia and hypomagnesaemia is
not expected.