When Insulin Must Wait: The Role of Renal Replacement Therapy in Refractory Hypokalemia During Severe Diabetic Ketoacidosis.
Sawsan Al-Lababidi, Muhammed Umer, Maria B Herrera-Gonzalez et al.
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Case in brief
A 37-year-old man presented with abdominal pain, progressive dyspnea, drowsiness, and Kussmaul respirations. Testing showed severe diabetic ketoacidosis (DKA), acute kidney injury, and severe hypokalemia. Insulin was withheld initially, and intravenous potassium did not provide sustained correction, repeatedly interrupting insulin treatment. Emergency intermittent hemodialysis was followed by continuous renal replacement therapy (CRRT); potassium and creatinine improved, acidosis lessened, and the anion gap closed, allowing insulin to continue. Despite biochemical improvement, he developed septic shock, disseminated intravascular coagulation, and catastrophic intracerebral hemorrhage and died.
What made this case unusual
Refractory hypokalemia prevented sustained insulin treatment, prompting emergency hemodialysis followed by CRRT as an adjunct to metabolic stabilization in DKA.
Diagnostic / clinical pearl
In DKA with severe hypokalemia, insulin may need to be withheld until potassium is corrected; when supplementation fails, this report describes renal replacement therapy as an adjunct that enabled insulin to resume.
Why it matters
Closure of the anion gap and improvement in laboratory measures did not equate to clinical recovery in this critically ill patient.