We report a series of 8 patients with critical illness and diabetes mellitus who developed euglycemic ketosis during continuous kidney replacement therapy (CKRT) with a glucose-free CKRT solution. Two patients had chronic kidney disease stage 5, while the rest had acute kidney injury. The patients had improvement in all metabolic parameters following CKRT commencement, except for a worsening high anion gap metabolic acidosis, in spite of improvement in serum lactate. This led to detection of raised serum beta-hydroxybutyrate in the setting of normoglycemia. Following diagnosis of ketosis, the patients’ caloric intake was increased from a median of 15 (10-20) to 25 (20-29) kcal/kg/day by adding a dextrose infusion. This allowed for a corresponding increase in the insulin administered, from a median of 0.2 (0-0.2) to 3.0 (2.3-3.9) units/hour. These contributed to a complete resolution of ketosis. This case series demonstrates that critically ill patients are at risk of developing euglycemic ketosis during CKRT, which can be mitigated by providing adequate caloric intake and using glucose-containing CKRT solutions with appropriate insulin therapy. We recommend vigilance in evaluating for euglycemic ketosis in patients who have a persistent metabolic acidosis despite improvements in solute control during CKRT.
Copyright © 2020. Published by Elsevier Inc.

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