SMJ | Diabetic Ketoalkalosis in Children and Adults
  • Join
  • Renew
  • Login
Southern Medical Association
Skip to content
  • About
    • Leadership
    • The Pulse
    • Promotional Opportunities
    • Website Development
    • Endowment
      • Scholarships
    • Contact
  • Membership
    • Group Membership
    • Physician MD/DO
    • Healthcare Professional
    • Healthcare Management
    • Resident
    • Medical Student
    • SMA Alliance
  • Education
    • CME Accreditation
    • Online CME
    • Live Events
    • Podcasts
    • Abstract Submission
  • Southern Medical Journal
    • Bioethics & Medical Education
    • Women’s & Children’s Health
    • Medicine & Medical Specialties
    • Public Health & Environmental Medicine
    • Quality Health Care, Patient Safety, & Best Practice
    • Surgery & Surgical Specialties
    • Mental Health
    • Emergency & Disaster Medicine
  • SMA Connect
Tags: Original Article | Medicine & Medical Specialties, SMJ Article | View Full Issue
Current User S2 Access Level: -1 ( )
CAN NOT ACCESS LEVEL 2

Diabetic Ketoalkalosis in Children and Adults

Emily A. Huggins, MD, Shawn A. Chillag, MD, Ali A. Rizvi, MD, Robert R. Moran, PhD, Martin W. Durkin, MD, MPH
Pages: 6-10
DOI: 10.1097/SMJ.0000000000000040
Volume: 107 Issue: 1 January, 2014
  • Abstract
  • Article
  • Images
  • References
  • CME
  • Discuss
  • SDC

Abstract

Objectives

Diabetic ketoacidosis (DKA) with metabolic alkalosis (diabetic ketoalkalosis [DKALK]) in adults has been described in the literature, but not in the pediatric population. The discordance in the change in the anion gap (AG) and the bicarbonate is depicted by an elevated delta ratio (DR; rise in AG/drop in bicarbonate), which is normally approximately 1. The primary aim of this study was to determine whether DKALK occurs in the pediatric population, as has been seen previously in the adult population. The secondary aim was to determine the factors that may be associated with DKALK.

Methods

A retrospective analysis of adult and pediatric cases with a primary or secondary discharge diagnosis of DKA between May 2008 and August 2010 at a large urban hospital was performed. DKALK was assumed to be present if the DR was >1.2 or in cases of elevated bicarbonate.

Results

Of 190 DKA cases, 91 were children, with 21% fulfilling the criterion for DKALK. There were 99 adult cases, 35% of which fulfilled the criterion for DKALK. Our final logistic model revealed that among patients with a discharge diagnosis of DKA, male patients, patients with a history of renal failure, and patients presenting with abdominal findings on physical examination were at greater odds of having a concomitant metabolic alkalosis.

Conclusions

Although DKALK has been described in adults, it can occur in a significant number of children presenting with DKA. The recognition of DKA can be obscured in such situations unless the AG and DR are calculated because the pH and bicarbonate may be near normal or even elevated. In addition to having interesting biochemical features as a complex acid-base disorder, DKALK can pose diagnostic and/or therapeutic challenges.

Article

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

Images:

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References:

1. Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009; 32: 1335–1343.
View Full Text | PubMed | CrossRef
 
2. Bleicher S. Ketosis not always acidosis: “heartburn” can be relevant. Diabetes. Outlook. 1967; 2: 3–4.
 
 
3. Webster GD Jr, Touchstone JC, Suzuki M. Adrenocortical hyperplasia occurring with metastatic carcinoma of the prostate: report of a case exhibiting increased urinary aldosterone and glucocorticoid excretion. J Clin Endocrinol Metab. 1959; 19: 967–979.
PubMed | CrossRef
 
4. Rastegar A. Use of the delta AG/deltaHCO3- ratio in the diagnosis of mixed acid-base disorders. J Am Soc Nephrol. 2007; 18: 2429–2431.
PubMed | CrossRef
 
5. Whittier WL, Rutecki GW. Primer on clinical acid-base problem solving. Dis Mon. 2004; 50: 122–162.
PubMed | CrossRef
 
6. Iqbal SJ, Walsh DB. Diabetic ketoalkalosis: a readily diagnosed non-entity. Br Med J. 1976; 2: 1389
PubMed | CrossRef
 
7. Chillag SA, Bardoner J, McDonald D, et al.Prevalence and risk factors for “diabetic ketoalkalosis” complicating admissions for diabetic ketoacidosis at a large teaching hospital. http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=81233. Published June 2010. Accessed April 25, 2013.
 
 
8. Cameron FJ, Hawkins KC, Khadikar VV, et al. Insulin-dependent diabetes mellitus presenting with ketoalkalosis in Rett syndrome. Diabet Med. 1997; 14: 884–885.
PubMed | CrossRef
 
9. Haber RJ. A practical approach to the acid-base disorders. West J Med. 1991; 155: 146–151.
PubMed
 
10. Wrenn K. The delta (delta) gap: an approach to mixed acid-base disorders. Ann Emerg Med. 1990; 19: 1310–1313.
PubMed | CrossRef
 
11. Androgue HJ, Wilson H, Boyd AE, et al. Plasma acid-base patterns in diabetic ketoacidosis. N Engl J Med. 1982; 307: 1603–1610.
PubMed | CrossRef
 
12. Elisaf MS, Tsatsoulis AA, Katopodis KP, et al. Acid-base and electrolyte disturbances in patients with diabetic ketoacidosis. Diabetes Res Clin Pract. 1996; 34: 23–27.
PubMed | CrossRef
 
13. Paulson WD, Gadallah MF. Diagnosis of mixed acid-base disorders in diabetic ketoacidosis. Am J Med Sci. 1993; 306: 295–300.
View Full Text | PubMed | CrossRef
 
14. Bustamante EA, Levy H. Severe alkalemia, hyponatremia, and diabetic ketoacidosis in an alcoholic man. Chest. 1996; 110: 273–275.
View Full Text | PubMed | CrossRef
 
15. Capps N, Jessamine S, Slater S. Diabetic ketoalkalosis: a complex mixed acid-base disorder. Scott Med J. 1986; 31: 182–183.
PubMed
 
16. Cronin JW, Kroop SF, Diamond J, et al. Alkalemia in diabetic ketoacidosis. Am J Med. 1984; 77: 192–194.
PubMed | CrossRef
 
17. Fulop M. Metabolic acidosis with alkalemia. NY State J Med. 1980; 80: 1365–1368.
PubMed
 
18. Goldman JM, Chiriboga M. Diabetic ketoacidosis with alkalemia. J Emerg Med. 1989; 7: 369–372.
PubMed | CrossRef
 
19. Greco AV, Bertoli A, Caputo S, et al. Ketoalkalosis as a result of triple derangement of acid-base equilibrium in a diabetic patient. Acta Diabetol Lat. 1985; 22: 73–77.
PubMed
 
20. Hudson B, Evans J. Adrenocortical hyperplasia associated with bronchogenic carcinoma. J Clin Endocrinol Metab. 1962; 22: 494–500.
PubMed | CrossRef
 
21. Jensen IW, Jensen S. Diabetic ketoalkalosis. Diabetes Care. 1988; 11: 368–369.
PubMed
 
22. Jerrard D, Hanna J. Diabetic ketoacidosis with alkalemia. Am J Emerg Med. 2002; 19: 521–522.
View Full Text | PubMed | CrossRef
 
23. Jimenez JA, Daminano A, Fernandez E, et al. Metabolic alkalosis in diabetic ketosis. JAMA. 1975; 233: 1193–1194.
PubMed | CrossRef
 
24. Koett J, Howell J, Steinberg S, et al. Diabetic ketoalkalosis. Clin Chem. 1979; 25: 1329–1330.
PubMed
 
25. Lim KC, Walsh CH. Diabetic ketoalkalosis: a readily misdiagnosed entity. Br Med J. 1976; 2: 19
PubMed | CrossRef
 
26. Melrose E, Morgan A, Harrower AD, et al. Diabetic ketoalkalosis. Br Med J. 1976; 2: 237
PubMed | CrossRef
 
27. Pearson DW, Thomson JA, Kennedy AC, et al. Diabetic ketoalkalosis due to ectopic ACTH production from an oat cell carcinoma. Postgrad Med J. 1981; 57: 455–456.
PubMed | CrossRef
 
28. Prando R, Odetti P, Deferrari G. Metabolic alkalosis in diabetic ketosis: a case report. Diabetes Metab. 1984; 10: 218–220.
PubMed
 
29. O’Reilly DS, Delamere JP. Cause of alkalosis in “diabetic ketoalkalosis.” Clin Chem. 1980; 26: 171–172.
PubMed
 
30. Pape A, Nguyen HV, Flack JR. Recurrent diabetic ketoalkalosis in a patient with type 1 diabetes mellitus and severe gastroparesis. Diabetes Med. 2010; 27: 607–608.
View Full Text | PubMed | CrossRef
 
31. Roggin GM, Moses D, Kautcher M, et al. Ketosis and metabolic alkalosis in a patient with diabetes. JAMA. 1970; 211: 296–298.
PubMed | CrossRef
 
32. Sanders G, Boyle G, Hunter S, et al. Mixed acid-base abnormalities in diabetes. Diabetes Care. 1978; 1: 362–364.
PubMed | CrossRef
 
33. Shirley R, Martin JV. Diabetic ketoalkalosis. Br Med J. 1976; 2: 943
PubMed | CrossRef
 
34. Watanabe Y, Noda K, Akazawa K, et al. Two cases of type 1 diabetic women with diabetic ketoacidosis presenting as alkalemia. Diabetes Res Clin Pract. 2009; 83: e54–e57.
PubMed | CrossRef
 
35. Zonszein J, Baylor P. Diabetic ketoacidosis with alkalemia—a review. West J Med. 1988; 149: 217–219.
PubMed
 
36. Adrogue H, Barrero J, Dolson G. Diabetic ketoacidosis. In: Suki W, Massry S. (eds). Therapy of Renal Diseases and Related Disorders. New York: Springer; 1991; : 197
 

CME:

This article has been developed as a Journal CME Activity by the Southern Medical Association. Visit http://sma.inreachce.com to view instructions, documentation, and the complete necessary steps to receive CME credit for reading this article. Fees may apply. CME credit will be available for 2 years after date of publication.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

Login to View or Purchase Create a Free Account

Quick Links

  • About SMA
  • Promotional Opportunities
  • Privacy Policy – Terms of Use
  • The Southern Medical Journal
  • Contact Us

Contact Us

3500 Blue Lake Drive, Suite 360
Birmingham, AL 35243
E-mail: [email protected]
Toll Free: (800) 423-4992
Telephone: (205) 945-1840
Fax Number (205) 945-1830

Follow Us

Sign Up for Our Newsletter!

Sign Up Here!

Southern Medical Association is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

© 2019 Southern Medical Association , all rights reserved

Southern Medical Association is a 501(c)3 Non-Profit organization. EIN: 63-0196615.

s2Member®
SMA Menu
  • About
    ▽
    • Leadership
    • The Pulse
    • Promotional Opportunities
    • Website Development
    • Endowment
    • Contact
  • Membership
    ▽
    • Group Membership
    • Physician DO/MD
    • Healthcare Professional
    • Healthcare Management
    • Resident
    • Medical Student
    • SMA Alliance
  • Education
    ▽
    • CME Accreditation
    • Online CME
    • Live Events
    • Podcasts
    • Abstract Submission
  • Southern Medical Journal
    ▽
    • Bioethics & Medical Education
    • Women’s & Children’s Health
    • Medicine & Medical Specialties
    • Public Health & Environmental Medicine
    • Quality Health Care, Patient Safety, & Best Practices
    • Surgery & Surgical Specialities
    • Mental Health
    • Emergency & Disaster Medicine
  • SMA Connect