Case Report: Refractory mixed acidosis with iatrogenic hyperchloremic acidosis in diabetic ketoacidosis
Year: 2026
Type: article
Study design: Case Report
Abstract: This case highlights a critical but easily overlooked complication of diabetic ketoacidosis (DKA) management—iatrogenic hyperchloremic acidosis superimposed on ketoacidosis—and demonstrates the role of the Δ gap (ΔAG − ΔHCO 3 - ) in identifying refractory mixed acidosis. The “peripheral metabolic pool” hypothesis is proposed as a possible additional mechanism for persistent pH deterioration despite improvement in central metabolic parameters. A 32-year-old woman with type 2 diabetes presented with severe DKA (pH 6.974) after excessive durian and beer consumption. Despite initial improvement in glucose and ketone levels, her pH paradoxically worsened to 6.84 with progressive hyperchloremia (96.8 to 115 mmol/L), leading to acute heart failure, acute kidney injury , among others. The Δ gap=ΔAG-ΔHCO 3 - <-6 suggested the possible coexistence of high anion-gap ketoacidosis and normal anion-gap hyperchloremic acidosis, consistent with a mixed acidosis. Urinary β 2 -microglobulin >4000 μg/L indicated proximal tubular injury. Continuous renal replacement therapy (CRRT) was initiated at 14 hours after admission; acidosis was successfully corrected after 12 hours of CRRT, with gradual recovery of organ function. Recognition of mixed acidosis and timely individualized CRRT were important in breaking this patient’s vicious cycle. Clinicians should avoid excessive chloride load in DKA management and consider balanced crystalloids after initial resuscitation.
Source: Frontiers in Endocrinology
Institutions: Fujian Medical University, Fujian Provincial Hospital
Language: English
Subfield: Nephrology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,801
OpenAlex ID: W7223130227