Preventing Iatrogenic Euglycemic Diabetic Ketoacidosis in Cardiac Surgery: The Role of Sodium-Glucose Cotransporter 2 Inhibitors.

To the Editor We read with interest the article by Auerbach et al. regarding the incidence of euglycemic diabetic ketoacidosis (eDKA) in patients using sodium-glucose cotransporter 2 inhibitors (SGLT2i) after cardiac surgery.1 The study addresses an important topic considering the increasing use of SGLT2i in clinical practice. The reported incidence of eDKA (15%) raises important concerns, particularly in high-volume cardiac centers where a substantial number of patients may be affected. We would like to highlight a few points that require further consideration. The definition of eDKA used by the authors did not include measurement of ketonemia and plasma beta-hydroxybutyrate levels. Indeed, the presence of urine ketones may be related to other conditions (e.g., prolonged fasting, carbohydrate deprivation). The presence of postoperative acidosis with low plasma bicarbonate levels after cardiac surgery also lacks specificity and may be related to acute kidney injury or low cardiac output syndrome.2,3 The timing of eDKA and its associated temporal metabolic findings would provide additional insights into the status of the patients. The timing of drug discontinuation and the impact of carbohydrate supplementation (such as those provided intraoperatively or with enhanced recovery after surgery protocols) on glucose metabolism are also crucial to evaluating risk of eDKA.4 1Auerbach JS, Gershengorn HB, Aljure OD, et al. Postcardiac Surgery Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Cotransporter 2 Inhibitors. J Cardiothor Vasc An. 2023;37:956–63.2Bell J, Sartipy U, Holzmann MJ, et al. The Association Between Acute Kidney Injury and Mortality After Coronary Artery Bypass Grafting Was Similar in Women and Men. J Cardiothor Vasc An. 2022;36:962–70.3Wang Y, Bellomo R. Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment. Nat Rev Nephrol. 2017;13:697–711.4Halvorsen S, Mehilli J, Cassese S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022;43:3826–924. Department funding solely.