Solutions for Diabetic Ketoacidosis: Finding the Right Balance

Recent studies have shown improved renal outcomes in adult patients with sepsis receiving balanced solutions instead of "normal" saline. For years, it has been known that 0.9% saline (colloquially referred to as "abnormal saline") can cause a hyperchloremic (non-anion gap) metabolic acidosis. The SMART and SALT-ED studies showed worsened acute kidney injury and greater dialysis in patients with septic shock treated with 0.9% saline compared with a balanced solution with a significantly lower chloride concentration. The findings led to increased use of balanced solutions in patients with sepsis and suggested that those with other clinical conditions may benefit from this approach — specifically, patients with diabetic ketoacidosis (DKA). In the case of DKA, we need a solution that can restore euvolemia and mitigate the underlying acidosis.

In 2017, an Australian group of researchers compared Hartmann solution (lactated Ringer) vs 0.9% saline in a small number of children with DKA. There was no difference between the two treatments in the time to resolution of the acidosis, as measured by a serum bicarbonate level > 14 mEq/L; however, the researchers did not evaluate renal outcomes.

In the SPinK trial, pediatric patients with DKA were randomly assigned to receive Plasma-Lyte A (balanced solution) or 0.9% saline. Any patient presenting in hypovolemic shock was first resuscitated with a bolus of the fluid type they were assigned. Once shock resolved, the patients were treated until their total fluid deficit was corrected or their glucose reached ≤ 250 mg/dL.

Figure. Download here.

After a 48-hour treatment window, the rate of new or worsening acute kidney injury was the same in both treatment arms. Both SPinK and the Australian study suggest no advantage for balanced solutions over 0.9% saline. Were the studies too small (< 70 kids in each trial), or are the renoprotective effects of balanced solutions best seen in adults with septic shock and not children with DKA?

At this point it is unclear, but given the cost of Plasma-Lyte A and the ubiquity of "abnormal saline" (eg, 0.45% saline, D5 + 0.45% saline, etc.), it may be wise to continue saline resuscitation in this specific population. What is your preferred resuscitative/maintenance fluid for both adult and pediatric patients with DKA?

Tejas Desai is a practicing nephrologist in Charlotte, North Carolina. His academic interests include the use of social media for physician, student, and patient education. He is the founder of NOD Analytics, a free social media analytics group that serves the medical education community. He has two wonderful children and enjoys spending time with them and his wife.

Follow Tejas P. Desai, MD, on Twitter: @nephondemand

Follow Medscape on Facebook, Twitter, Instagram, and YouTube