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Myeloma Hypercalcaemia Osteoclast Cytokine Mechanism — ESENeph MCQ

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HardElectrolyte DisordersMyeloma Hypercalcaemia Osteoclast Cytokine MechanismESENeph

A patient with CKD G4, diabetes and acute gastroenteritis takes dapagliflozin. Glucose is 10.2 mmol/L, beta-hydroxybutyrate 4.1 mmol/L, bicarbonate 12 mmol/L and pH 7.24. Which diagnosis and medication action are most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Euglycaemic DKA; stop dapagliflozin and start protocolised intravenous DKA treatment

Explanation lettering: C = shown as B · B = shown as C

E is correct. The patient has ketonaemia, high-anion-gap metabolic acidosis and only modest hyperglycaemia during acute illness while taking an SGLT2 inhibitor: this is euglycaemic DKA until proved otherwise. Dapagliflozin is stopped and standard urgent DKA treatment is initiated, with careful fluid and potassium management in CKD. Starvation ketosis is usually less acidotic, and CKD-related acidosis does not explain marked beta-hydroxybutyrate. SGLT2-associated DKA can occur below conventional glucose thresholds, so waiting for severe hyperglycaemia would be dangerous. Future restart requires review of the precipitant and recurrence risk.

Reference: UK Kidney Association SGLT2-inhibitor guideline: acute illness and hypovolaemia: https://guidelines.ukkidney.org/sodium-glucose-co-transporter-2/5c-acute-kidney-injury-hypovolaemia-and-potassium/