Haemodiafiltration as a treatment option in refractory life-threatening diabetic ketoacidosis

Background: Fulminant diabetic ketoacidosis (DKA) with a pH of <6.9 can be refractory to DKA management protocols and there is no consensus/evidence to suggest intravenous bicarbonate use. Here we attempt to describe a case of fulminant DKA without renal failure where haemofiltration was done for severe metabolic acidosis with excellent results. Case history: A 23-year-old female presented to the emergency department via ambulance after out-of-hospital arrest and returned to spontaneous circulation after resuscitation. She was found to be in severe DKA with pH of 6.752, HCO₃ of 1.3mmol/L, lactate 3.1mmol/L and creatinine 133μmol/L; and despite maximal DKA treatment with maximum insulin infusion titration, at 15 units per hour and 5 litres of IV fluid, remained in severe metabolic acidosis with pH 6.772. After discussion with critical care and endocrine colleagues regarding options of using intravenous bicarbonate therapy versus haemofiltration, she was put on haemofiltration which resolved the metabolic acidosis completely within 12 hours. Discussion: Our patient with severe refractory DKA responded to haemofiltration with resolution of severe metabolic acidosis; we feel that haemofiltration in these situations may be considered as an option to correct persistent metabolic acidosis in refractory fulminant DKA.