OBJECTIVE: Diabetic ketoacidosis (DKA) is classically associated with high anion gap metabolic acidosis. However, non-anion gap metabolic acidosis (NAGMA) can be seen in DKA due to hyperchloremic state during rehydration therapy and hypophosphatemia. Comprehensive look of all electrolytes should be done to prevent misdiagnosed which can lead to severe complications of DKA.
CASE: An overweight 17-years-old boy came to local clinic with nausea and vomiting for 5 days and was diagnosed with dyspepsia. One day before admission, patient showed worsening mental status with hyperglycemia (682 mg/dl). Despite initiation therapy of rehydration with normal saline, insulin, bicarbonate patient keep deteriorating and transferred to our emergency unit. On admission, he was on mechanical ventilation, coma with complete signs of distributive shock. Laboratory results showed hyperglycemia (262.2 mg/dl), hyperketonemia (4.3 mmol/L), pH 7.224, HCO3 9.0 mmol/L, Na 134 mEq/L, Cl 117 mEq/L, Albumin 2.56 with anion gap 8.0 mEq/L, delta ratio -0.3 suggests hyperchloremic NAGMA with Urea (83.6 mg/dL), Creatinine (5.239) which could be mislead as stress hyperglycemia in septic shock. However, comprehensive electrolytes investigation showed hypophosphatemia (1.0 mg/dl), hypokalemia (2.3 mEq/L) which conclude severe DKA presenting NAGMA with acute kidney injury. He was admitted to the pediatric intensive care unit for 8 days and rehydrated with lactated Ringer’s solution without kalium chloride and corrected with serial kalium dihydrogen phosphate infusion and hemodialysis. After 17 days, he was discharged with good result.
CONCLUSION: Doctors should be aware of NAGMA because this condition could also be found in DKA especially after rehydrated with normal saline. Ignoring NAGMA could lead to hypophosphatemia, one of the most common complication of DKA that could lead to hemodynamic disturbance due to its negative inotropic. Early diagnosis and prompt treatment prevent complications of DKA and reduces risk of mortality and morbidity.