This protocol addresses the next step for patients presenting with diabetic ketoacidosis who have end-stage renal disease or are on maintenance dialysis, specifically when the initial treatment approach has not met the target rate of glucose reduction.

Clinical Scenario

When DKA occurs in end-stage renal disease (CKD stage 5) or in patients on dialysis, several specific issues must be considered. Insulin replacement is the mainstay of treatment in this population, but the clinical context introduces distinct challenges that require careful management.

Previous Treatment — Target Not Met

The initial step for this population uses a fixed rate intravenous insulin infusion. The treatment goal is to reduce blood glucose at a rate of 3.0 mmol/L/hour. When that rate of glucose fall is not achieved with the initial infusion rate, escalation to the next management step is required.

Next Step — Partial Overview

The next approach centres on adjusting the intravenous insulin infusion rate to achieve the required glucose fall; if significant hyperkalaemia develops, urgent specialist renal involvement may be necessary — the complete structured regimen is available via the protocol below.

References

When DKA does occur in end stage renal disease, several issues need to be considered.
For people with end stage renal failure or those on dialysis, insulin replacement is the mainstay of treatment.
This should be given as a FRIII at an initial rate of 0.1 units/kg/hr, but may need to increase if the required rate of glucose fall is not achieved.
In this circumstance, continuous cardiac monitoring is essential and critical care or the specialist renal team should be involved to consider urgent haemodialysis / haemofiltration.
However, the rate of glucose reduction is the same as for people with preserved renal function – i.e. 3.0 mmol/L/hour.

View source ↗

DKA in End-Stage Renal Disease: When Initial Insulin Infusion Fails to Achieve the Required Glucose Reduction

References