Correlation of acidosis-adjusted potassium level and cardiovascular outcomes in diabetic ketoacidosis: a systematic review

Atif Usman,1 Mohd Makmor Bakry,2 Norlaila Mustafa,3 Inayat Ur Rehman,1,4 Allah Bukhsh,1,5 Shaun Wen Huey Lee,1 Tahir Mehmood Khan1,5,61School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia; 2Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia; 3Department of Endocrinology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia; 4Department of Pharmacy, Abdul Wali Khan University, Mardan, Pakistan; 5Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan; 6Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes, Health and Well-being Cluster, Global Asia in the 21st Century Platform, Monash University Malaysia, Selangor, MalaysiaBackground: During the progress and resolution of a diabetic ketoacidosis (DKA) episode, potassium levels are significantly affected by the extent of acidosis. However, none of the current guidelines take into account acidosis during resuscitation of potassium level in DKA management, which may increase the risk of cardiovascular adverse events.Objective: To assess literature regarding the adjustment of potassium level using pH to calculate pH-adjusted corrected potassium level, and to observe the relationship of cardiovascular outcomes with reported potassium level and pH-adjusted corrected potassium in DKA.Methodology: Seven databases were searched from inception to January 2018 for studies which had reported people with diabetes developing diabetic ketoacidosis, in relation to prevalence or incidence, fluid resuscitation or potassium supplementation treatment, treatment or cardiovascular outcomes, and experimentation with DKA management or insulin. Quality of studies was evaluated using Cochrane Risk of Bias and Newcastle Ottawa Scale.Results: Forty-seven studies were included in qualitative synthesis out of a total of 10,292 retrieved studies. Forty-one studies discussed the potassium level and blood pH at the time of admission, ten studies discussed cardiovascular outcomes, and only four studies concurrently discussed potassium level, pH, and cardiovascular outcomes. Only two studies were graded as good on the Newcastle Ottawa Scale. The reported potassium level was well within normal range (5.8 mmol/L), whereas pH rendered patients to be moderately acidotic (7.13). Surprisingly, none of the included studies mentioned pH-adjusted corrected potassium level and, hence, this was calculated later. Although mean corrected potassium was within the normal range (3.56 mmol/L), 13 studies had corrected potassium below 3.5 mmol/L and five had it below 3.0 mmol/L. Nevertheless, with the exception of one study, none discussed cardiovascular outcomes in the context of potassium or pH-adjusted potassium level.Conclusion: The evidence surrounding cardiovascular outcomes during DKA episodes in light of a pH-adjusted corrected potassium level is scarce. A prospective observational, or preferably, an experimental study in this regard will ensure we can modify and enhance safety of existing DKA treatment protocols.Keywords: diabetic ketoacidosis, potassium, hypokalemia, blood gasses, acidosis, pH, treatment outcomes, cardiovascular, insulin

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