Inadequate Caloric Intake and Glucose-Free Dialysate Induce Euglycemic Diabetic Ketoacidosis in a Patient Receiving SGLT2 Inhibitors: A Case Report and Literature Review

Abstract Background Euglycemic diabetic ketoacidosis (eu-DKA) is a rare complication in patients receiving sodium-glucose cotransporter-2 (SGLT2) inhibitors, and it is characterized by elevated urinary ketone and/or serum ketone levels and glucose < 11.1 mmol/L. The eu-DKA is frequently underdiagnosed and can lead to severe clinical consequences. Case Presentation We report the case of a 53-year-old man with type 2 diabetes treated with SGLT2 inhibitors who underwent continuous veno-venous hemodialysis (CVVHD) with a glucose-free dialysate because of hypernatremia and metabolic acidosis (MA) after coronary artery bypass grafting and ventricular aneurysmectomy.The patient had high anion gap MA with a normal serum lactate level, which could not be corrected by CVVHD. He was later diagnosed to have eu-DKA with a strong positive result for urinary ketones. Glucose loss through urine was 27.3 g/d, while estimated glucose loss through CVVHD was 41.5 g/d. After withdrawal of SGLT2 inhibitors and supplementation with calories (increasing from 12.3–14.2 to 15.5–23.8 kcal/kg/d), glucose (increasing from 0.6–1.0 to 1.4–3.4 g/kg/d), and insulin (increasing from 0.67 to 1.8–5.2 U/kg/d), MA disappeared within 14 h, and urinary ketones were negative. CVVHD was then successfully terminated. Conclusion This case suggested that maintaining adequate caloric intake and avoiding glucose-free dialysate were essential to treat eu-DKA in patients receiving SGLT2 inhibitors.