Abstract Introduction Diabetic ketoacidosis (DKA) is a common and treatable hyperglycemic emergency, but when complicated by profound electrolyte derangements and delayed insulin therapy, it may progress to life-threatening metabolic failure. This case illustrates the role of continuous renal replacement therapy (CRRT) as rescue management in refractory DKA and highlights the socioeconomic barriers to insulin access as a preventable precipitant of critical illness. Case Presentation A 48-year-old man with insulin-dependent type 2 diabetes, alcohol use disorder, and suspected substance use was found unresponsive at home. Family reported he had been unable to afford insulin for over a month after losing insurance coverage. On arrival, he was obtunded with left gaze deviation, prompting stroke activation. CT head and CTA were unremarkable. Serum glucose was 600 mg/dL, and he was intubated for airway protection. ICU assessment confirmed severe DKA with metabolic encephalopathy.Initial labs: pH 6.89, bicarbonate 4 mmol/L, anion gap 36, β-hydroxybutyrate 9 mmol/L, potassium 2.9 mmol/L, phosphate 1 mg/dL, lactate 5.1 mmol/L. Insulin therapy was held due to critical hypokalemia. Despite aggressive fluid resuscitation and electrolyte repletion, he remained severely acidemic with hemodynamic instability. Continuous renal replacement therapy (CRRT) was started on hospital day 2 for refractory metabolic acidosis.During CRRT, urine output exceeded 500 mL/hour despite minimal fluid intake, suggesting renal recovery. By day 3, the anion gap closed, acidosis resolved, and CRRT was discontinued. The patient was transitioned to subcutaneous insulin, extubated, and broad-spectrum antibiotics were de-escalated after a negative infectious workup. Discussion This case demonstrates the life-threatening potential of DKA when compounded by profound electrolyte derangements, delayed insulin initiation, and rapidly progressive acidosis. CRRT, while not routinely used in DKA, served as a lifesaving adjunct when conventional therapy failed. Beyond clinical complexity, this case represents a preventable pathway to critical illness, lack of access to insulin due to socioeconomic barriers. The patient’s deterioration was not due to nonadherence, but to structural inequities loss of insurance, medication unaffordability, and unstable housing which converted a manageable chronic disease into a critical care emergency. This case underscores the importance of advocating for equitable insulin access and the need for clinicians to recognize when social determinants of health directly drive critical presentations. This abstract is funded by: NA
Saeedi et al. (Fri,) studied this question.