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Euglycemic diabetic ketoacidosis
Cetoacidosis diabética euglucémica
Alejandro González-Castro, María Ortiz Lasa
Corresponding author
maralasa111@gmail.com

Corresponding author.
, Andrés Jiménez Alfonso
Hospital Universitario Marqués de Valdecilla, Santander, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetic ketoacidosis &#40;DKA&#41; is one of the most serious complications of diabetes&#46; It is characterized by the triad of hyperglycemia&#44; metabolic acidosis and ketosis&#46; Hyperglycemia is considered a key criterion in the diagnosis of DKA&#46; However&#44; rarely&#44; blood glucose levels can be within normal range&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> This entity is known as euglycemic DKA&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case report of an euglycemic DKA episode in a patient with known type 1 diabetes mellitus&#44; triggered by a sodium glucose transporter 2 &#40;SGLT2&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This was a 51-year-old male patient with a history of type 2 diabetes mellitus with poor glycemic control &#40;HbA1 11&#37;&#41; under treatment with a SGLT2 &#40;empagliflozin&#41;&#46; He went to the Emergency Department of our hospital for recent asthenia&#44; hyporexia&#44; nausea and malaise plus decreased level of consciousness on the day of admission&#46; Upon arrival in the Emergency Department&#44; he presented a poor general condition with altered level of consciousness&#44; dehydrated and poorly perfused&#46; He was tachycardic and tachypneic with shallow breathing and no other changes during examination&#46; He was referred to the Intensive Care Unit of our hospital&#46; The first blood test showed glucose 185<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; ketones 6&#46;2<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#44; urea 164<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; creatinine 1&#46;62<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; PCR 19&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; PCT 6&#46;15<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; with normal electrolyte levels and normal liver function tests&#46; The blood count showed 14&#44;000 leukocytes&#44; hemoglobin 11&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dl and platelets 195&#44;000&#44; with normal coagulation profile&#46; Arterial-blood gas test showed a severe metabolic acidosis with pH 7&#46;08&#44; bicarbonate levels 5&#46;3 and base excess by &#8722;26&#44;200&#46; The first hours of hospital admission the patient&#39;s condition worsened despite the administration of intensive fluid therapy and sodium bicarbonate&#44; requiring orotracheal intubation&#44; sedoanalgesia and connection to mechanical ventilation as well as renal replacement therapy &#40;continuous veno-venous hemodiafiltration&#41;&#46; Euglycemic ketoacidosis was suspected&#46; Therefore&#44; insulin perfusion was also started&#44; being necessary for 3 days until the normalization of blood ketones&#44; keeping normal blood glucose levels&#46; After onset of renal replacement therapy&#44; the patient evolved favorably and the acid&#8211;base balance parameters went back to normal&#46; Therefore&#44; the patient could be extubated and the hemofilter was removed at 24<span class="elsevierStyleHsp" style=""></span>h&#46; On the fourth day he was discharged after withdrawal of insulin perfusion and normalization of the ketones&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Euglycemic DKA is a rare entity&#44; which occurs with blood glucose levels below 200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Potential etiologies of euglycemic DKA include recent use of insulin&#44; poor caloric intake&#44; alcohol consumption&#44; chronic liver disease&#44; and glycogen storage disorders&#46; The recent use of SGLT2 inhibitors has become a potential mechanism of euglycemic DKA&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">SGLT2 inhibitors reduce blood glucose levels&#44; increase urinary glucose excretion and decrease insulin secretion from pancreatic B cells&#46; This results in a decreased lipolysis and the stimulation of free fatty acids&#44; which are turned into ketones in the liver&#46; On the other hand&#44; SGLT2 inhibitors are also associated with an increased glucagon production&#46; The lowering of the insulin&#8211;glucagon ratio further stimulates lipolysis and increases the circulation of free fatty acids and lipid oxygenation&#46; In addition&#44; SGLT2 receptors have been identified in pancreatic cells where their inhibition promotes the secretion of glucagon&#44; which helps increase the production of ketones&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Euglycemic DKA poses a challenge to physicians&#44; since patients with normal blood glucose levels in ketoacidosis may be underestimated&#44; leading to a delay in treatment approaches&#46; Despite normoglycemia&#44; ketoacidosis remains a medical emergency and should be treated quickly and appropriately&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Thus&#44; in early detection of ketosis when the first symptoms occur &#40;malaise&#44; nausea&#44; and&#47;or vomiting&#41; the recommendations should be to temporarily withdraw SGLT2 inhibitors&#44; hydration&#44; frequent consumption of carbohydrates and administration of complete doses of insulin to prevent progression to DKA&#46; In fact&#44; in this context&#44; the temporary withdrawal of these drugs during acute illness or surgery are reasonable&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand&#44; diabetic patients assume that their condition is not related to diabetes mellitus if their blood glucose levels are not significantly increased&#46; However&#44; patients taking SGLT2 inhibitors should be trained to test their ketones in urine&#44; if they present any symptoms&#44; regardless of low or normal blood glucose levels&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p></span>"
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Article information
ISSN: 23870206
Original language: English
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es en pt

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