INS and hypophosphatemia: In DKA, net (urinary) loss of phosphate occurs because of a transcellular shift, osmotic diuresis and reduced renal phosphate reabsorption by the Na-Pi transporters in the renal proximal tubule (due to acidosis and hyperglycemia).5 During insulin and fluid repletion in the treatment of DKA, phosphate shifts from the extracellular to the intracellular compartment, worsening hypophosphatemia.