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Southern Medical Journal:
doi: 10.1097/SMJ.0000000000000040
Medicine & Medical Subspecialties

Diabetic Ketoalkalosis in Children and Adults

Huggins, Emily A. MD; Chillag, Shawn A. MD; Rizvi, Ali A. MD; Moran, Robert R. PhD; Durkin, Martin W. MD, MPH

Continued Medical Education
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Diabetic ketoacidosis (DKA) with metabolic alkalosis (diabetic ketoalkalosis [DKALK]) in adults has been described in the literature, but not in the pediatric population. The discordance in the change in the anion gap (AG) and the bicarbonate is depicted by an elevated delta ratio (DR; rise in AG/drop in bicarbonate), which is normally approximately 1. The primary aim of this study was to determine whether DKALK occurs in the pediatric population, as has been seen previously in the adult population. The secondary aim was to determine the factors that may be associated with DKALK.


A retrospective analysis of adult and pediatric cases with a primary or secondary discharge diagnosis of DKA between May 2008 and August 2010 at a large urban hospital was performed. DKALK was assumed to be present if the DR was >1.2 or in cases of elevated bicarbonate.


Of 190 DKA cases, 91 were children, with 21% fulfilling the criterion for DKALK. There were 99 adult cases, 35% of which fulfilled the criterion for DKALK. Our final logistic model revealed that among patients with a discharge diagnosis of DKA, male patients, patients with a history of renal failure, and patients presenting with abdominal findings on physical examination were at greater odds of having a concomitant metabolic alkalosis.


Although DKALK has been described in adults, it can occur in a significant number of children presenting with DKA. The recognition of DKA can be obscured in such situations unless the AG and DR are calculated because the pH and bicarbonate may be near normal or even elevated. In addition to having interesting biochemical features as a complex acid-base disorder, DKALK can pose diagnostic and/or therapeutic challenges.

Copyright © 2014 by The Southern Medical Association


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