Euglycemic Diabetic Ketoacidosis With Sepsis and Acute Kidney Injury in Critically Ill Patients: A Case Series

Diabetic ketoacidosis (DKA) typically presents with hyperglycemia, but euglycemic diabetic ketoacidosis (EDKA) occurs when patients present with acidosis and normal blood glucose levels. This condition has garnered attention due to its association with sodium-glucose cotransporter-2 (SGLT2) inhibitors and other factors such as sepsis. Acute kidney injury (AKI) often complicates sepsis cases and is associated with metabolic acidosis. Distinguishing between AKI and EDKA can be difficult, particularly when both conditions co-occur, as observed in three ICU cases of sepsis with AKI and EDKA. In this report, the clinical challenges of diagnosing EDKA in critically ill patients, especially in the presence of metabolic acidosis and an elevated anion gap, are highlighted. In these cases, metabolic acidosis was initially attributed to AKI; however, blood ketone levels were essential for confirming EDKA. Treatment for EDKA was prioritized over kidney replacement therapy (KRT), which was only initiated when needed for AKI management. Despite its potential benefits in managing AKI, KRT's role in EDKA treatment requires further investigation. This report emphasizes the importance of early diagnosis of EDKA in diabetic patients with sepsis and AKI, stressing the need for prompt ketone testing and insulin therapy, while acknowledging the ongoing uncertainties surrounding the impact of KRT on prognosis in EDKA cases.