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Author Notes:

Correspondence: Professor Guillermo E Umpierrez; gneumpie@emory.edu

Author contributions: RJG and GEU designed the study and wrote the manuscript. FJP, MF, KT, ND, SC, HW, and PV contributed to the study design, data collection, data analysis and reviewed/edited the manuscript.

RJG and GEU are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.


Research Funding:

Research reported in this publication was supported by a grant to RJG from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institute of Health Under Award number P30DK11102. RJG received research support to Emory University for investigator-initiated studies from Novo Nordisk, and consulting fees from Abbott Diabetes Care, Sanofi and Novo Nordisk.

PV is supported in part by the National Institute of Health grant 3K12HD085850 and has received consulting fees from Merck and Boehringer Ingelheim. FJP is supported in part by the National Institute of Health grant 1K23GM128221-01A1 and received consulting fees from Boehringer Ingelheim, Eli Lilly and AstraZeneca. GEU is partly supported by research grants from the National Center for Advancing Translational Sciences of the National Institutes of Health under Award number UL1TR002378 from the Clinical and Translational Science Award program and a National Institutes of Health (NIH) grant U30, P30DK11102, and has received research grant support to Emory University for investigator-initiated studies from Sanofi, Novo Nordisk, and Dexcom.


  • Science & Technology
  • Life Sciences & Biomedicine
  • Endocrinology & Metabolism
  • ketoacidosis
  • dialysis
  • ESRD
  • hypoglycemia
  • Severe hyperglycemia
  • Chronic dialysis
  • Adult patients
  • Potassium
  • Insulin

Clinical characteristics and outcomes of patients with end-stage renal disease hospitalized with diabetes ketoacidosis


Journal Title:

BMJ Open Diabetes Research & Care


Volume 8, Number 1


Type of Work:

Article | Final Publisher PDF


Introduction: There is limited evidence to guide management in patients with end-stage renal disease (ESRD) on chronic hemodialysis admitted with diabetes ketoacidosis. Thus, we investigated the clinical characteristics and outcomes of patients with ESRD admitted with diabetic ketoacidosis (DKA). Methods: In this observational study, we used International Classification of Diseases Ninth/Tenth Revision codes to identify adult (aged 18-80 years) patients admitted to Emory University Hospitals between 1 January 2006 and 31 December 2016. DKA and ESRD diagnoses were confirmed by reviewing medical records and by admission laboratory results. Results: Among 307 patients with DKA meeting the inclusion and exclusion criteria, 22.1% (n: 68) had ESRD on hemodialysis and 77.9% (n: 239) had preserved renal function (estimated glomerular filtration rate >60 mL/min/1.73 m 2). Compared with patients with preserved renal function, the admission blood glucose was higher (804.5±362.6 mg/dL vs 472.5±137.7 mg/dL) and the mean hemoglobin A1c was lower (9.6%±2.1 vs 12.0%±2.5) in patients with DKA and ESRD, both p<0.001. The rates of hypoglycemia <70 mg/dL (34% vs 14%, p=0.002) and <54 mg/dL (13% vs 5%, p=0.04) were higher in the ESRD group. During hospitalization, more patients with ESRD develop volume overload (28% vs 3%, p<0.001) and require mechanical ventilation (24% vs 3%, p=<0.001). There were no differences in hospital mortality (3% vs 0%, p=0.21), but length of stay (median 7.0 vs 3.0 days, p<0.001) was longer in the ESRD cohort. After adjusting for multiple covariates, patients with DKA and ESRD have higher odds of hypoglycemia (OR 3.3, 95% CI 1.51 to 7.21, p=0.003) and volume overload (OR 4.22, 95% CI 1.37 to 13.05, p=0.01) compared with patients with DKA with preserved renal function. Conclusions: Patients with DKA and ESRD on chronic hemodialysis had worse clinical outcomes including higher rates of hypoglycemia, volume overload, need for mechanical ventilation and longer length of stay, compared with patients with preserved kidney function.

Copyright information:

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

This is an Open Access work distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).
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