Diabetic ketoacidosis as the initial presentation of hepatogenous diabetes: a first reported case.

Summary: Hepatogenous diabetes, a secondary form of diabetes arising from chronic liver disease, particularly cirrhosis, is a well-documented complication. However, diabetic ketoacidosis (DKA) in the context of hepatogenous diabetes has not been reported in the literature. We report the case of a 60-year-old male with alcoholic liver cirrhosis and no prior history of diabetes who presented with altered mental status and was diagnosed with DKA. Initial lab tests revealed severe hyperglycemia, high-anion gap metabolic acidosis, and an elevated HbA1C of 10.2%, a significant increase from 5.2% five months earlier. The patient was managed with insulin and lactulose, resulting in clinical improvement. Follow-up revealed normalization of HbA1C and a reduction in insulin requirements. This is the first documented case of DKA as the initial presentation of hepatogenous diabetes, emphasizing the need for heightened awareness and further research into its clinical manifestations and management. Key clinical messages: DKA can be the first clinical manifestation of hepatogenous diabetes, even in patients with normal HbA1C and no prior diabetes history. HbA1C is an unreliable marker for diagnosing diabetes in cirrhotic patients due to shortened red blood cell lifespan; OGTT should be considered when hepatogenous diabetes is suspected despite normal glycemic markers. Subclinical infections can precipitate DKA in cirrhosis through stress-induced insulin resistance.