Rhabdomyolysis, acute kidney injury and diabetic ketoacidosis all are life-threatening conditions. Coincidence of them can be missed because the patient is usually asymptomatic or has mild symptoms related to rhabdomyolysis. The development of rhabdomyolysis as a complication of diabetic ketoacidosis is not well understood and only a few clinical studies address the phenomenon. We are reporting, along with a literature review, a 39-year-old male, who presented with diabetic ketoacidosis complicated with rhabdomyolysis and acute kidney injury. To the best of our knowledge, this is the first case reported in the United Arab Emirates. We highlight the syndrome because it is curable with early detection and proper treatment.
The world diabetes prevalence in adults in 2021 was estimated to be 10.5% [
A 39-year-old male was recently diagnosed with hypertension, for which he took an over-the-counter antihypertension medication; the patient was unsure about the name of the drug. However, he did not use it for one week prior to admission. He presented to our emergency department with generalized fatigability, nausea, and abdominal discomfort. On the clinical examination, he was conscious, slightly confused and dehydrated. His chest was clear on auscultation and his abdomen was soft and lax. In the emergency department, the patient’s Venous blood gas (VBG) confirmed the diagnosis of diabetic ketoacidosis (anion gap 35 mEq/L, pH < 7.08, serum bicarbonate 6.5 mEq/L, serum ketones more than 7 mmol/L, blood Glucose 33.3 mmol/L). This is the first presentation for his diabetes. The Lab results revealed acute kidney injury and elevated creatinine kinase. Upon further history taking, he mentioned mild diffuse lower limb pain bilaterally. He denied fever, strenuous exercise or prolonged exposure to the sun. No recent use of herbal, alcohol, or recreational drugs was recorded. No history of recent trauma or abnormal movements. The Imaging studies reported a normal ultrasound scan study of the abdomen and pelvis and in the chest x-ray, there was no detectable pulmonary consolidation. The laboratory investigation on admission showed in
The patient was treated according to the diabetic ketoacidosis protocol as well as alkalization of urine and his condition showed significant improvement.
A few cases reports in the literature have mentioned the association of hypophosphatemia, severe acidosis, and high osmolality as contributors to rhabdomyolysis in a patient with DKA.
I. A 31-year-old male presented with two weeks history of polyuria, polydipsia, and nocturia and showed up at ED with epigastric abdominal pain, nausea, and non-bloody vomiting. The patient was in a diabetic ketoacidosis episode in which rhabdomyolysis developed and complicated into acute renal failure. [
II. A 12-year-old female was admitted to the hospital with severe DKA, severe metabolic acidosis, hypophosphatemia, rhabdomyolysis, and oliguria ARF. [
III. Two type 2 diabetes mellitus (T2DM) adolescent patients who had diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) predisposing
| Test | Result | Normal reference range |
|---|---|---|
| Hgb | 12.40 gm/dL | 13 - 17 gm/dL |
| Platelet | 152.00 k | 150 - 450 k |
| Sodium | 123.00 mmol/L | 136 - 145 mmol/L |
| Potassium | 5.29 mmol/L (high) | 3.5 - 5.1 mmol/L |
| Magnesium | 1.1 mmol/L | 0.66 - 1.07 mmol/L |
| Creatinine | 173 decreased to 81 umol/L (high) | 59 - 104 umol/L |
| Urea | 23.10 mmol/L | 2.76 - 8.07mmol/L |
| Calcium | 2.02 mmol/L | 2.15 - 2.5 mmol/L |
| Phosphorus | 0.14 mmol/L (low) | 0.37 - 1.47 nmol/L |
| Total CK | 2356.00 increased to 14816.00 U/L ((high) | 20 - 200 U/L |
| C-Peptide | 0.289 nmol/L | 0.37 - 1.47 nmol/L |
| HbA1C% | 13.70 % (high) | 4.8% - 6% |
| CRP | 14.46 mg/L | 0 - 5 mg/L |
| Myoglobin | 705.90 ng/mL (high) | 28 - 72 ng/mL |
rhabdomyolysis (RM) [
The Na/K-ATPase pump actively controls the transport across the cell membrane and maintained the charges gradient. These processes depend on ATP as a source of energy. ATP (adenosine triphosphate) depletion appears to be the end result of most causes of rhabdomyolysis. The depletion disrupts cellular transport mechanisms. [
Rhabdomyolysis in the context of diabetic ketoacidosis is usually overlooked because the patient is asymptomatic or has mild symptoms related to rhabdomyolysis. However, it may lead to permanent kidney damage and progress to chronic kidney disease. We advise focusing on the possible coincidence of Rhabdomyolysis while treating patients with diabetic ketoacidosis. Further studies to understand the underlying pathophysiology and prevalence are recommended.
DKA: diabetic ketoacidosis; CK: creatinine kinase; ED: emergency department; ARF: acute renal failure; ATP: adenosine triphosphate.
The authors declare no conflicts of interest regarding the publication of this paper.
Hamid, A. and Alshaali, A (2023) Adult Patient with Diabetic Ketoacidosis and Rhabdomyolysis. International Journal of Clinical Medicine, 14, 228-232. https://doi.org/10.4236/ijcm.2023.144018