Kidney Replacement Therapy as a Rescue Strategy for Severe Acidosis in Diabetic Ketoacidosis: A Case Report

INTRODUCTION: Diabetic ketoacidosis is a serious complication mainly affecting individuals with type 1 diabetes. It occurs due to insulin deficiency, leading to high blood glucose levels and ketone production, which causes metabolic acidosis. Treatment involves fluid resuscitation, insulin therapy, and correcting metabolic imbalances. Complications can arise from insulin resistance and acidosis. In severe cases of refractory metabolic acidosis, renal replacement therapy can improve outcomes by correcting potassium levels and aiding recovery. METHODS: A 43-year-old Iranian woman with poorly controlled type 2 diabetes was admitted to Imam Reza Hospital with diabetic ketoacidosis. Despite initial treatment at a local health center, she required hemodialysis due to persistent severe metabolic acidosis. FINDINGS: After hemodialysis and further treatment in the intensive care unit, her condition improved, and she was discharged on a multiple daily injection insulin regimen. The patient's presentation was complex, with hypokalemia being a rare finding in an initial diabetic ketoacidosis presentation. DISCUSSION: The refractory hypokalemia was likely due to prolonged gastrointestinal losses from vomiting. The most significant error in management was the delay in initiating insulin infusion despite the diabetic ketoacidosis diagnosis. Renal replacement therapy was used as a salvage method to correct severe acidosis and potassium deficits, showing its potential effectiveness in such cases.