Management of Diabetic Ketoacidosis with Acute Kidney Injury Requiring Continuous Renal Replacement Therapy

Introduction to CRRT in DKA

The American College of Nephrology recommends the use of continuous venovenous hemodiafiltration (CVVHDF) or hemofiltration (CVVHF) rather than intermittent hemodialysis for hemodynamically unstable patients with lactic acidosis and severe metabolic derangements 1, 3
The target effluent dose for adequate solute clearance and metabolic control is 20-25 mL/kg/hour 1, 4
Bicarbonate-buffered dialysate/replacement fluid should be used instead of lactate-buffered solutions to avoid worsening acidosis in patients with impaired lactate metabolism 1

The American Diabetes Association recommends targeting a plasma glucose level of 110-149 mg/dL (6.1-8.3 mmol/L) using continuous IV insulin infusion 5
Avoid tight glycemic control (80-110 mg/dL) as it increases the risk of hypoglycemia without providing a mortality benefit 5

The National Kidney Foundation recommends monitoring potassium levels every 2-4 hours initially, despite normal current levels, as insulin therapy and correction of acidosis can drive potassium intracellularly, causing potentially severe hypokalemia 6
Potassium-containing dialysate (2-4 mEq/L) should be used to prevent hypokalemia during CRRT 6
Phosphate levels should be monitored every 6-12 hours as hypophosphatemia occurs in 60-80% of ICU patients on CRRT 6
Phosphate-containing dialysate solutions should be used to prevent severe hypophosphatemia, which is associated with worse outcomes 6
Magnesium levels should be monitored daily as hypomagnesemia occurs in 60-65% of critically ill patients on CRRT 6
Magnesium-containing dialysate should be used as magnesium losses during CRRT are substantial, especially with citrate anticoagulation 6

The American College of Chest Physicians recommends using regional citrate anticoagulation rather than heparin for CRRT, unless contraindicated 1
Ionized calcium levels should be monitored closely (every 4-6 hours) as citrate chelates calcium 1, 6

The European Society for Clinical Nutrition and Metabolism recommends providing 1.5-1.7 g/kg/day protein once hemodynamically stable, as CRRT causes continuous amino acid losses (10-15 g/day) 6, 4
The target total energy intake should be 20-30 kcal/kg/day to prevent catabolism 5, 8
Water-soluble vitamins, especially thiamine, folate, and vitamin C, should be supplemented as CRRT causes massive losses 6

Blood glucose levels should be monitored hourly until stable, then every 2-4 hours 5
Potassium levels should be monitored every 2-4 hours initially, then every 4-6 hours 6
Phosphate levels should be monitored every 6-12 hours 6
Magnesium levels should be monitored daily 6
Ionized calcium levels should be monitored every 4-6 hours if using citrate 1, 6
CRRT delivered dose should be continuously monitored to ensure the target 20-25 mL/kg/hour is achieved 1