Managing diabetic ketoacidosis in special conditions: Difficulties and dilemmas

Table 1 Key management principles of management of diabetic ketoacidosis in different co-morbid conditions

Disease	Key management principles
DKA with chronic kidney disease	Routine bolus fluid replacement is not needed in euvolemic patients
	In patients with hypovolemia, small aliquot of 250 mL i.v. fluid should be given slowly
	In severe hypervolemia with refractory pulmonary oedema, hemodialysis may be needed
	Lower dose of fixed rate intravenous insulin infusion (0.05 units/kg/hour) is preferred in ESRD patients
	Routine supplementation of potassium is not recommended
	In case of severe hyperkalemia (> 6.5 mmol/L), hemodialysis may even be required
	Bicarbonate therapy can rarely be required in pre-existing chronic metabolic acidosis (pH < 7.2) after nephrology consultation
DKA with heart failure	Strict advanced hemodynamic monitoring is needed for assessment of volume status
	Cautious and slow replacement of minimal fluid bolus (250-500 mL) at a time, only if required
	Concentrated dextrose infusion may be needed (25%dextrose) in patients with hypervolemia
	Persistent hypotension can be due to HF and will require administration of vasoactive agents
	Treatment of precipitating factors including any cardiac events
	Modifications of chronic medications (discontinuation SGLT2i)
DKA with acute pancreatitis	Early initiation of fluid replacement and intravenous insulin infusion
	Early diagnosis and prompt initiation of management of acute pancreatitis
	Use of intravenous insulin infusion will also help reduce concomitant hypertriglyceridemia, if any

DKA: Diabetic ketoacidosis; ESRD: End stage renal disease; i.v.: Intravenous; SGLT2i: Sodium-glucose cotransporter-2 inhibitors; HF: Heart failure.