When Insulin Must Wait: The Role of Renal Replacement Therapy in Refractory Hypokalemia During Severe Diabetic Ketoacidosis

Objective:Unusual clinical course Background:Diabetic ketoacidosis (DKA) is a common life-threatening metabolic emergency characterized by hyperglycemia, high-anion-gap metabolic acidosis, and ketosis.Severe hypokalemia before insulin therapy is uncommon but may complicate management and delay treatment. Case Report:A 37-year-old man presented to the emergency department with a 2-day history of generalized abdominal pain and progressive shortness of breath.He was drowsy and tachypneic, with Kussmaul respirations.Laboratory evaluation revealed severe DKA, acute kidney injury, and severe hypokalemia.Insulin therapy was initially withheld according to the DKA protocol.Intravenous potassium supplementation failed to achieve sustained correction, resulting in repeated interruptions of insulin therapy.Due to refractory hypokalemia, an emergency 2-hour session of intermittent hemodialysis was performed, followed by continuous renal replacement therapy (CRRT).During CRRT, serum potassium increased, serum creatinine decreased, metabolic acidosis improved, and the anion gap closed.Insulin therapy was resumed without further interruption.However, the clinical course was complicated by severe septic shock, disseminated intravascular coagulation, and catastrophic intracerebral hemorrhage, ultimately resulting in death. Conclusions:Severe hypokalemia at presentation in DKA poses a critical therapeutic challenge because insulin therapy must be withheld until the electrolyte abnormality is corrected.In rare cases of refractory hypokalemia, CRRT may serve as an adjunctive strategy to facilitate metabolic stabilization and safe DKA management.This case adds to the limited literature and highlights the need for further studies to clarify the role and effectiveness of this approach.Biochemical resolution of DKA may not correspond to clinical recovery, and critically ill patients warrant continuous monitoring.