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Aboghanem A, Prasad GVR. Disorders of potassium homeostasis after kidney transplantation. World J Transplant 2024; 14:95905. [PMID: 39295980 PMCID: PMC11317851 DOI: 10.5500/wjt.v14.i3.95905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/29/2024] [Accepted: 06/26/2024] [Indexed: 07/31/2024] Open
Abstract
Disturbances of potassium balance are often encountered when managing kidney transplant recipients (KTR). Both hyperkalemia and hypokalemia may present either as medical emergencies or chronic outpatient abnormalities. Despite the high incidence of hyperkalemia and its potential life-threatening implications, consensus on its management in KTR is lacking. Hypokalemia in KTR is also well-described, although it is given less attention by clinicians compared to hyperkalemia. This article discusses the etiology, pathophysiology and management of both types of potassium disorders in KTR. Once any emergent situation has been corrected, treatment approaches include correcting insulin deficiency if present, adjusting non-immunosuppressive and immunosuppressive medications, eliminating or supplementing potassium as needed, and dietary counselling. Although commonly of multifactorial etiology, ascertaining the specific cause in a particular patient will help guide successful management. Monitoring KTR through regular laboratory testing is essential to detect serious disturbances in potassium balance since patients are often asymptomatic.
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Affiliation(s)
| | - G V Ramesh Prasad
- School of Medicine, University of Toronto, Toronto M5C 2T2, Ontario, Canada
- Kidney Transplant Program, St. Michael's Hospital, Toronto M5C 2T2, Ontario, Canada
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2
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Abstract
Patients with alcohol use disorders are commonly identified and managed in the emergency department. Although the alcohol-intoxicated patient has a high risk for significant injury and diseases, the majority will be allowed to sober in the emergency department and can be discharged without incident. However, there are metabolic derangements in these patients, such as alcoholic ketoacidosis, Wernicke-Korsakoff, and potomania that very commonly present similar to intoxication and can be misdiagnosed by emergency clinicians.
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Affiliation(s)
| | - Julie Gorchynski
- Department of Emergency Medicine, UT Health San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229-3900, USA.
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3
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Chandra P, Kaleem M, Sachan N, Pathak R, Alanazi AS, Alsaif NA, Alsanea S, Alsuwayt B, Alanazi MM, Kabra A. Gastroprotective evaluation of Medicago sativa L. (Fabaceae) on diabetic rats. Saudi Pharm J 2023; 31:101815. [PMID: 37860685 PMCID: PMC10582054 DOI: 10.1016/j.jsps.2023.101815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 10/01/2023] [Indexed: 10/21/2023] Open
Abstract
Traditional uses for the plant Medicago sativa (M. sativa) (Alfalfa) (Family: Fabaceae) include liver protection, antioxidant activity, and the treatment of bleeding and digestive issues. This study aims to assess the effect of ethanol extract of M. sativa (EEMS) on experimental-induced ulcers in diabetic rats. By pylorus ligation and ethanol administration, gastric ulcers were induced in diabetic rats. Five groups each consisting of six rats in each model were used. All other groups except Group I were made diabetic by giving rats alloxan (140 mg/kg i.p.). Vehicles were given to Group I (normal control) and Group II (diabetes control) rats. Group III (positive control) received ranitidine 50 mg/kg, and Group IV and V received EEMS at doses of 100 and 400 mg/kg, respectively. In the pylorus ligation and ethanol-induced stomach ulcer model of rats, the findings demonstrated that EEMS (100 mg/kg) showed a decreased ulcer index of 2.01 ± 0.41 and was found statistically significant against the diabetes control group (p < 0.001) as well as, an ulcer index of 0.68 ± 0.22 by EEMS (400 mg/kg) with a significant reduction in the ulcer index (p < 0.001). EEMS (100 and 400 mg/kg) reduce free acidity by 13.16 ± 0.65 mEq/L and 9.83 ± 0.30 mEq/L, respectively. EEMS also showed a protective impact on the liver and kidneys of diabetic rats. Antihyperglycemic action was also discovered in diabetic animals. The findings of the current investigation demonstrated that ethanolic extract of M. sativa possesses anti-ulcer activity in diabetic rats. Ethanolic extract of M. sativa may be a treatment option for stomach ulcers that also have diabetes.
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Affiliation(s)
- Phool Chandra
- Teerthanker Mahaveer College of Pharmacy, Teerthanker Mahaveer University, Moradabad, U.P. 244001, India
| | - Mohammad Kaleem
- School of Pharmaceutical Sciences, IFTM University, Lodhipur Rajput, Delhi Road (NH-24), Moradabad 244 102, U.P., India
| | - Neetu Sachan
- Maharana Pratap College of Pharmacy, Mandhana, Kanpur 209217, U.P., India
| | - Rashmi Pathak
- Department of Pharmacy, Invertis University, Bareilly 243123, U.P., India
| | - Ashwag S. Alanazi
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Nawaf A. Alsaif
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia
| | - Sary Alsanea
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
| | - Bader Alsuwayt
- Department of Pharmacy Practice, College of Pharmacy, University of Hafr Al-Batin, Hafr Al-Batin 31991, Saudi Arabia
| | - Mohammed M. Alanazi
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia
| | - Atul Kabra
- University Institute of Pharma Sciences, Chandigarh University, Mohali 140301, Punjab, India
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4
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Al-Qusairi L, Ferdaus MZ, Pham TD, Li D, Grimm PR, Zapf AM, Abood DC, Tahaei E, Delpire E, Wall SM, Welling PA. Dietary anions control potassium excretion: it is more than a poorly absorbable anion effect. Am J Physiol Renal Physiol 2023; 325:F377-F393. [PMID: 37498547 PMCID: PMC10639028 DOI: 10.1152/ajprenal.00193.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 07/28/2023] Open
Abstract
The urinary potassium (K+) excretion machinery is upregulated with increasing dietary K+, but the role of accompanying dietary anions remains inadequately characterized. Poorly absorbable anions, including [Formula: see text], are thought to increase K+ secretion through a transepithelial voltage effect. Here, we tested if they also influence the K+ secretion machinery. Wild-type mice, aldosterone synthase (AS) knockout (KO) mice, or pendrin KO mice were randomized to control, high-KCl, or high-KHCO3 diets. The K+ secretory capacity was assessed in balance experiments. Protein abundance, modification, and localization of K+-secretory transporters were evaluated by Western blot analysis and confocal microscopy. Feeding the high-KHCO3 diet increased urinary K+ excretion and the transtubular K+ gradient significantly more than the high-KCl diet, coincident with more pronounced upregulation of epithelial Na+ channels (ENaC) and renal outer medullary K+ (ROMK) channels and apical localization in the distal nephron. Experiments in AS KO mice revealed that the enhanced effects of [Formula: see text] were aldosterone independent. The high-KHCO3 diet also uniquely increased the large-conductance Ca2+-activated K+ (BK) channel β4-subunit, stabilizing BKα on the apical membrane, the Cl-/[Formula: see text] exchanger, pendrin, and the apical KCl cotransporter (KCC3a), all of which are expressed specifically in pendrin-positive intercalated cells. Experiments in pendrin KO mice revealed that pendrin was required to increase K+ excretion with the high-KHCO3 diet. In summary, [Formula: see text] stimulates K+ excretion beyond a poorly absorbable anion effect, upregulating ENaC and ROMK in principal cells and BK, pendrin, and KCC3a in pendrin-positive intercalated cells. The adaptive mechanism prevents hyperkalemia and alkalosis with the consumption of alkaline ash-rich diets but may drive K+ wasting and hypokalemia in alkalosis.NEW & NOTEWORTHY Dietary anions profoundly impact K+ homeostasis. Here, we found that a K+-rich diet, containing [Formula: see text] as the counteranion, enhances the electrogenic K+ excretory machinery, epithelial Na+ channels, and renal outer medullary K+ channels, much more than a high-KCl diet. It also uniquely induces KCC3a and pendrin, in B-intercalated cells, providing an electroneutral KHCO3 secretion pathway. These findings reveal new K+ balance mechanisms that drive adaption to alkaline and K+-rich foods, which should guide new treatment strategies for K+ disorders.
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Affiliation(s)
- Lama Al-Qusairi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Mohammed Z Ferdaus
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Truyen D Pham
- Department of Medicine Nephrology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Dimin Li
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - P Richard Grimm
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Ava M Zapf
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Delaney C Abood
- Department of Medicine Nephrology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Ebrahim Tahaei
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Eric Delpire
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Susan M Wall
- Department of Medicine Nephrology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Paul A Welling
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Physiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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Glaser NS, Stoner MJ, Kwok MY, Quayle KS, Brown KM, Schunk JE, Trainor JL, McManemy JK, Tzimenatos L, Rewers A, Nigrovic LE, Bennett JE, Myers SR, Smith M, Casper TC, Kuppermann N. Relationships among biochemical measures in children with diabetic ketoacidosis. J Pediatr Endocrinol Metab 2023; 36:313-318. [PMID: 36637392 PMCID: PMC9986464 DOI: 10.1515/jpem-2022-0570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/14/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Investigating empirical relationships among laboratory measures in children with diabetic ketoacidosis (DKA) can provide insights into physiological alterations occurring during DKA. We determined whether alterations in laboratory measures during DKA conform to theoretical predictions. METHODS We used Pearson correlation statistics and linear regression to investigate correlations between blood glucose, electrolytes, pH and PCO2 at emergency department presentation in 1,681 pediatric DKA episodes. Among children with repeat DKA episodes, we also assessed correlations between laboratory measures at the first vs. second episode. RESULTS pH and bicarbonate levels were strongly correlated (r=0.64), however, pH and PCO2 were only loosely correlated (r=0.17). Glucose levels were correlated with indicators of dehydration and kidney function (blood urea nitrogen (BUN), r=0.44; creatinine, r=0.42; glucose-corrected sodium, r=0.32). Among children with repeat DKA episodes, PCO2 levels tended to be similar at the first vs. second episode (r=0.34), although pH levels were only loosely correlated (r=0.19). CONCLUSIONS Elevated glucose levels at DKA presentation largely reflect alterations in glomerular filtration rate. pH and PCO2 are weakly correlated suggesting that respiratory responses to acidosis vary among individuals and may be influenced by pulmonary and central nervous system effects of DKA.
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Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California, Davis Health, University of California Davis, School of Medicine, Sacramento, USA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, USA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, USA
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, Saint Louis, USA
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The George Washington School of Medicine and Health Sciences, Washington DC, USA
| | - Jeff E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, USA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, USA
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, The Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Denver, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/A.I. DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - McKenna Smith
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis Health, University of California Davis, School of Medicine, Sacramento, USA.,Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, USA
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6
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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7
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Alexander E, Weatherhead J, Creo A, Hanna C, Steien DB. Fluid management in hospitalized pediatric patients. Nutr Clin Pract 2022; 37:1033-1049. [PMID: 35748381 DOI: 10.1002/ncp.10876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/28/2022] [Accepted: 05/21/2022] [Indexed: 11/09/2022] Open
Abstract
The proper use of intravenous fluids has likely been responsible for saving more lives than any other group of substances. Proper use includes prescribing an appropriate electrolyte and carbohydrate solution, at a calculated rate or volume, for the right child, at the right time. Forming intravenous fluid plans for hospitalized children requires an understanding of water and electrolyte physiology in healthy children and how different pathology deviates from the norm. This review highlights fluid management in several disease types, including liver disease, diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, kidney disease, and intestinal failure as well as in those with nonphysiologic fluid losses. For each disease, the review discusses specific considerations, evaluations, and management strategies to consider when customizing intravenous fluid plans. Ultimately, all hospitalized children should receive an individualized fluid plan with recurrent evaluations and fluid modifications to provide optimal care.
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Affiliation(s)
- Erin Alexander
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey Weatherhead
- Division of Pediatric Critical Care, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA
| | - Ana Creo
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA
| | - Christian Hanna
- Division of Pediatric Nephrology and Hypertension, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA.,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA
| | - Dana B Steien
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota, USA
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8
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Mahmoud H, Jaffar Z, Al Alawi YM, Al Alsuhaimi F, Khoja MAA, Al-Ahmadi MA, Alattas AM, Alhusayni MF, Mahroos ME, Alrehaili MA. Accuracy of Potassium Measurement Using Blood Gas Analyzer. Cureus 2022; 14:e23653. [PMID: 35371883 PMCID: PMC8971128 DOI: 10.7759/cureus.23653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction: Newer blood gas analyzers can measure both blood gases and electrolytes in both arterial and venous blood samples. They are small, compact, and mobile point of care test (POCT) devices. They can produce results in as short as five minutes. We aimed at assessing the accuracy of potassium (K) level measured by gas analyzer (index test) by comparing that to the regular laboratory machine (reference standard) in our hospital. Our goal is to use POCT result of potassium so we may start insulin infusion within five to 10 minutes of arrival of diabetic ketoacidosis (DKA) patients to the emergency room (ER). It takes an average of 30 minutes to get the result using the reference standard machine. Potassium level is needed urgently in cases of DKA before initiating insulin infusion. That is true also during cardiopulmonary resuscitation (CPR) and while replacing K in severe hypokalemia and during the management of hyperkalemia. Methods: We looked into the potassium results from 265 patients who had venous blood gas (VBG) or arterial blood gas (ABG) samples and compared that to results of potassium in venous blood samples of these same patients done simultaneously or within two hours. All patients who had blood gas and venous blood drawn simultaneously or within two hours were eligible irrespective of gender, age, diagnosis, and location in the hospital. Data were collected between January 2019 and June 2019. We excluded all cases that were receiving IV fluids, diuretics, or potassium supplements. Samples examined were from all different areas of the hospital including emergency room (ER), intensive care unit (ICU), and general floors. All ages and all diagnoses were included. Results: We used the Bland-Altman method to analyze our data. More than 95% of the data fell within ± 2 standard deviations (S) of the mean difference strongly suggestive of agreement between the index test and the standard reference of the laboratory methods. The bias was 0.19. Lin’s concordance correlation coefficient was 0.6584. Conclusion: Findings of this study support the use of POCT blood gas analyzer for measuring potassium when the results are needed urgently. When measuring potassium, blood gas analyzers are as accurate as automated analyzers. They produce results in five minutes or so and can be relied upon when potassium level is needed urgently. They are cost-effective and may be available at the bedside.
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Valdivielso JM, Balafa O, Ekart R, Ferro CJ, Mallamaci F, Mark PB, Rossignol P, Sarafidis P, Del Vecchio L, Ortiz A. Hyperkalemia in Chronic Kidney Disease in the New Era of Kidney Protection Therapies. Drugs 2021; 81:1467-1489. [PMID: 34313978 DOI: 10.1007/s40265-021-01555-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 12/20/2022]
Abstract
Despite recent therapeutic advances, chronic kidney disease (CKD) is one of the fastest growing global causes of death. This illustrates limitations of current therapeutic approaches and, potentially, unidentified knowledge gaps. For decades, renin-angiotensin-aldosterone system (RAAS) blockers have been the mainstay of therapy for CKD. However, they favor the development of hyperkalemia, which is already common in CKD patients due to the CKD-associated decrease in urinary potassium (K+) excretion and metabolic acidosis. Hyperkalemia may itself be life-threatening as it may trigger potentially lethal arrhythmia, and additionally may limit the prescription of RAAS blockers and lead to low-K+ diets associated to low dietary fiber intake. Indeed, hyperkalemia is associated with adverse kidney, cardiovascular, and survival outcomes. Recently, novel kidney protective therapies, ranging from sodium/glucose cotransporter 2 (SGLT2) inhibitors to new mineralocorticoid receptor antagonists have shown efficacy in clinical trials. Herein, we review K+ pathophysiology and the clinical impact and management of hyperkalemia considering these developments and the availability of the novel K+ binders patiromer and sodium zirconium cyclosilicate, recent results from clinical trials targeting metabolic acidosis (sodium bicarbonate, veverimer), and an increasing understanding of the role of the gut microbiota in health and disease.
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Affiliation(s)
- José M Valdivielso
- Vascular and Renal Translational Research Group, UDETMA, REDinREN del ISCIII, IRBLleida, Lleida, Spain.
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Robert Ekart
- Clinic for Internal Medicine, Department of Dialysis, University Medical Center Maribor, Maribor, Slovenia
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, 89124, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patrick Rossignol
- Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Alberto Ortiz
- School of Medicine, IIS-Fundacion Jimenez Diaz, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
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10
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Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State. J Emerg Med 2021; 61:365-375. [PMID: 34256953 DOI: 10.1016/j.jemermed.2021.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/16/2021] [Accepted: 05/30/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus. Therefore, it is important for emergency physicians to be aware of this unique diagnosis and treatment considerations. OBJECTIVE This manuscript reviews the emergency department evaluation and management of the adult patient with hyperglycemic hyperosmolar state. DISCUSSION Hyperglycemic hyperosmolar state is diagnosed by an elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status. Treatment involves fluid resuscitation and correction of electrolyte abnormalities. It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes. These patients are critically ill and generally require admission to an intensive care unit. CONCLUSIONS Hyperglycemic hyperosmolar state is associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - George C Willis
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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11
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Abraham S, Parekh J, Polisetty L, Gunasekaran K. Rapid resolution of life-threatening hyperkalaemia in diabetic ketoacidosis with intensive insulin therapy. BMJ Case Rep 2021; 14:e242536. [PMID: 33766978 PMCID: PMC8006825 DOI: 10.1136/bcr-2021-242536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Soniya Abraham
- Internal Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Jay Parekh
- Internal Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Lakshmi Polisetty
- Internal Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA
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12
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Lapolla A, Amaro F, Bruttomesso D, Di Bartolo P, Grassi G, Maffeis C, Purrello F, Tumini S. Diabetic ketoacidosis: A consensus statement of the Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology and Pediatric Diabetoloy (SIEDP). Nutr Metab Cardiovasc Dis 2020; 30:1633-1644. [PMID: 32771260 DOI: 10.1016/j.numecd.2020.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Diabetic ketoacidosis (DKA) is a serious medical emergency once considered typical of type 1 diabetes (T1DM), but now reported to occur in type 2 and GDM patients as well. DKA can cause severe complications and even prove fatal. The aim of our study was to review recent international and national guidelines on diagnosis, clinical presentation and treatment of diabetic ketoacidosis, to provide practical clinical recommendations. METHODS AND RESULTS Electronic databases (MEDLINE (via PUB Med), Scopus, Cochrane library were searched for relevant literature. Most international and national guidelines indicate the same accurate flow chart to diagnose, to evaluate from clinical and laboratory point of view, and treat diabetic ketoacidosis. CONCLUSION Prompt diagnosis, rapid execution of laboratory analysis and correct treatment are imperative to reduce the mortality related to diabetic ketoacidosis. These recommendations are designed to help healthcare professionals reduce the frequency and burden of DKA.
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Affiliation(s)
| | - Flavia Amaro
- Department of Pediatrics University of Chieti, Chieti, Italy
| | | | - Paolo Di Bartolo
- Ravenna Diabetes Clinic, Romagna Diabetes Network, Internal DPT of Romagna Local Health Autorithy, Italy; Chief Italian Association of Diabetologists (AMD), Rome, Italy
| | - Giorgio Grassi
- Endocrinology, Diabetology and Metabolic Unit, City of Health and Science Torino, Italy
| | - Claudio Maffeis
- Chief Italian Society of Pediatric Endocrinology and Diabetology (SIEDP), Torino, Italy; Chief Pediatric Diabetes and Metabolic Disorder Unit, University Hospital, Verona, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania Catania, Italy; Chief Italian Diabetes Society (SID), Rome, Italy
| | - Stefano Tumini
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Chieti Hospital, Chieti, Italy
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13
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Manappallil RG, Nambiar J. Hyperkalemic Cardiac Arrest in a Patient with Diabetic Ketoacidosis. Indian J Crit Care Med 2020; 24:737-738. [PMID: 33024389 PMCID: PMC7519603 DOI: 10.5005/jp-journals-10071-23526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Robin G Manappallil
- Department of Internal Medicine, Baby Memorial Hospital, Calicut, Kerala, India
- Robin G Manappallil, Department of Internal Medicine, Baby Memorial Hospital, Calicut, Kerala, India, Phone: +91 8547753396, e-mail:
| | - Jayasree Nambiar
- Department of Cardiology, Baby Memorial Hospital, Calicut, Kerala, India
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14
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Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Evaluation and Management of the Critically Ill Adult With Diabetic Ketoacidosis. J Emerg Med 2020; 59:371-383. [DOI: 10.1016/j.jemermed.2020.06.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/24/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
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15
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Alotaibi A, Aldoukhi A, Albdah B, Alonazi JA, Alseraya AS, Alrasheed N. Diabetic Ketoacidosis Treatment Outcome and Associated Factors Among Adult Patients Admitted to the Emergency Department and Medical Wards at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Cureus 2020; 12:e10067. [PMID: 32999787 PMCID: PMC7522050 DOI: 10.7759/cureus.10067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/27/2020] [Indexed: 11/05/2022] Open
Abstract
Background Diabetic ketoacidosis (DKA) is a life-threatening condition with high morbidity and mortality rates. It should be diagnosed immediately and managed intensively to prevent its significant complications. Objectives The aim of this study to assess DKA treatment outcome and associated factors among adult patients at King Abdulaziz Medical City Emergency Department and Medical Wards, Riyadh, Saudi Arabia. Materials and Methods A retrospective cross-sectional study was conducted using a chart review to assess DKA treatment outcome and associated factors. All patients who were admitted as DKA cases from September 2017 to August 2019 were selected by simple random sampling except those with incomplete charts or younger than 14 years. Data were entered and analyzed using SAS Version 9.4 (SAS Institute, Cary, NC, USA). Results A total of 223 reviewed charts were collected. The frequency of DKA recurrence in most of the patients was once per year (126 [56.5%]). The most common precipitating factor was inappropriate insulin therapy (104 [46.64%]). More than half of the patients (120 [53.81%]) got out of DKA management protocol within 24-72 hours with a hospital stay of less than or equal to five days. The mortality rate was 1.83%. Patients with two or more DKA episodes per year tended to be admitted to ICU more frequently than those with one episode (p=0.001). It was found that patients who had a duration of one to five years of diabetes mellitus were almost five times more likely to get out of DKA in more than 72 hours when compared with those who had a duration of more than five years (adjusted OR: 4.7; 95% CI: 1.34-16.60; p=0.01). Conclusions The findings of this study highlight that majority of DKA patients showed improvement and discharged with a very low mortality rate. Inappropriate insulin therapy was the most common precipitating factor; thus, educating diabetic patients about the complications of treatment non-compliance is an important part of management.
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Affiliation(s)
- Abdulaziz Alotaibi
- Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | - Bayan Albdah
- Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, SAU
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16
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Bansal S, Pergola PE. Current Management of Hyperkalemia in Patients on Dialysis. Kidney Int Rep 2020; 5:779-789. [PMID: 32518860 PMCID: PMC7270720 DOI: 10.1016/j.ekir.2020.02.1028] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with end-stage renal disease (ESRD) on maintenance dialysis have a high risk of developing hyperkalemia, generally defined as serum potassium (K+) concentrations of >5.0 mmol/l, particularly those undergoing maintenance hemodialysis. Currently, the key approaches to the management of hyperkalemia in patients with ESRD are dialysis, dietary K+ restriction, and avoidance of medications that increase hyperkalemia risk. In this review, we highlight the issues and challenges associated with effective management of hyperkalemia in patients undergoing maintenance dialysis using an illustrative case presentation. In addition, we examine the potential nondialysis options for the management of these patients, including use of the newer K+ binder agents patiromer and sodium zirconium cyclosilicate, which may reduce the need for the highly restrictive dialysis diet, with its own implication on nutritional status in patients with ESRD, as well as reducing the risk of potentially life-threatening hyperkalemia.
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Affiliation(s)
- Shweta Bansal
- Division of Nephrology, UT Health at San Antonio, San Antonio, Texas, USA
| | - Pablo E Pergola
- Division of Nephrology, UT Health at San Antonio, San Antonio, Texas, USA.,Renal Associates, P.A., San Antonio, Texas, USA
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17
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Pasquel FJ, Tsegka K, Wang H, Cardona S, Galindo RJ, Fayfman M, Davis G, Vellanki P, Migdal A, Gujral U, Narayan KMV, Umpierrez GE. Clinical Outcomes in Patients With Isolated or Combined Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State: A Retrospective, Hospital-Based Cohort Study. Diabetes Care 2020; 43:349-357. [PMID: 31704689 PMCID: PMC6971788 DOI: 10.2337/dc19-1168] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/24/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Many patients with hyperglycemic crises present with combined features of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The implications of concomitant acidosis and hyperosmolality are not well known. We investigated hospital outcomes in patients with isolated or combined hyperglycemic crises. RESEARCH DESIGN AND METHODS We analyzed admissions data listing DKA or HHS at two academic hospitals. We determined 1) the frequency distributions of HHS, DKA, and combined DKA-HHS (DKA criteria plus elevated effective osmolality); 2) the relationship of markers of severity of illness and clinical comorbidities with 30-day all-cause mortality; and 3) the relationship of hospital complications associated with insulin therapy (hypoglycemia and hypokalemia) with mortality. RESULTS There were 1,211 patients who had a first admission with confirmed hyperglycemic crises criteria, 465 (38%) who had isolated DKA, 421 (35%) who had isolated HHS, and 325 (27%) who had combined features of DKA-HHS. After adjustment for age, sex, BMI, race, and Charlson Comorbidity Index score, subjects with combined DKA-HHS had higher in-hospital mortality compared with subjects with isolated hyperglycemic crises (adjusted odds ratio [aOR] 2.7; 95% CI 1.4, 4.9; P = 0.0019). In all groups, hypoglycemia (<40 mg/dL) during treatment was associated with a 4.8-fold increase in mortality (aOR 4.8; 95% CI 1.4, 16.8). Hypokalemia ≤3.5 mEq/L was frequent (55%). Severe hypokalemia (≤2.5 mEq/L) was associated with increased inpatient mortality (aOR 4.9; 95% CI 1.3, 18.8; P = 0.02). CONCLUSIONS Combined DKA-HHS is associated with higher mortality compared with isolated DKA or HHS. Severe hypokalemia and severe hypoglycemia are associated with higher hospital mortality in patients with hyperglycemic crises.
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Affiliation(s)
| | - Katerina Tsegka
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | - Heqiong Wang
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Saumeth Cardona
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | | | - Maya Fayfman
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | - Georgia Davis
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | | | - Alexandra Migdal
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | - Unjali Gujral
- Rollins School of Public Health, Emory University, Atlanta, GA
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18
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Basnet S, Musaitif R, Khanal A, Powell K, Caprirolo G, Majcina R, Robbs RS. Effect of Potassium Infusions on Serum Levels in Children during Treatment of Diabetic Ketoacidosis. J Pediatr Intensive Care 2020; 9:113-118. [PMID: 32351765 DOI: 10.1055/s-0039-1700981] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 11/27/2019] [Indexed: 12/26/2022] Open
Abstract
A retrospective study was done to determine the effect of potassium (K + ) infusions on serum levels in children admitted to the pediatric intensive care unit (PICU) with diabetic ketoacidosis (DKA). Eighty-two percent of 92 cases studied received 40 mEq/L K + infusion over the treatment period of median 13.0 (interquartile range [IQR]: 7-18) hours. The median K + value at the end of this period was 3.9 (IQR: 3.4-4.2) mEq/L. There were 31 data points of low K + values (<3.5 mEq/L) and 4 high values (>5.5 mEq/L) during this treatment period. The K + infusions of 40 mEq/L may be sufficient to normalize serum K + when treating DKA.
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Affiliation(s)
- Sangita Basnet
- Division of Critical Care, Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois, United States
| | - Rawan Musaitif
- Department of Pediatrics, University of Illinois College of Medicine at Peoria, Illinois, United States
| | - Aayush Khanal
- Division of Critical Care, Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois, United States
| | - Kimberly Powell
- Division of Critical Care, Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois, United States
| | - Giovanna Caprirolo
- Division of Critical Care, Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois, United States
| | - Ryan Majcina
- Division of Critical Care, Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois, United States
| | - Randall S Robbs
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, Illinois, United States
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19
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Mutig K, Bachmann S. Hyperkalemia and blood pressure regulation. Nephrol Dial Transplant 2019; 34:iii26-iii35. [PMID: 31800077 DOI: 10.1093/ndt/gfz218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Indexed: 11/12/2022] Open
Abstract
Hypertension is common in the general population. Management of hypertensive patients at risk of hyperkalemia is challenging due to potential life-threatening complications such as cardiac arrest. Chronic hyperkalemia is often associated with impaired renal ability to excrete excessive potassium ions (K+). This may refer to chronic kidney disease or certain pharmacological interventions, including broadly used renin-angiotensin-aldosterone system and calcineurin inhibitors. Understanding the intrinsic mechanisms permitting kidney adaptations to hyperkalemia is critical for choosing therapeutic strategies. Valuable insights were obtained from the analysis of familial hyperkalemic hypertension (FHHt) syndrome, which became a classic model for coincidence of high blood pressure and hyperkalemia. FHHt can be caused by mutations in several genes, all of them resulting in excessive activity of with-no-lysine kinases (WNKs) in the distal nephron of the kidney. WNKs have been increasingly recognized as key signalling enzymes in the regulation of renal sodium ions (Na+) and K+ handling, enabling adaptive responses to systemic shifts of potassium homoeostasis consequent to variations in dietary potassium intake or disease. The WNK signalling pathway recruits a complex protein network mediating catalytic and non-catalytic effects of distinct WNK isoforms on relevant Na+- or K+-transporting proteins. In this review article, we summarize recent progress in understanding WNK signalling. An update of available models for renal adaptation to hyperkalemic conditions is presented. Consequences for blood pressure regulation are discussed. Pharmacological targeting of WNKs or their substrates offers promising options to manage hypertension while preventing hyperkalemia.
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Affiliation(s)
- Kerim Mutig
- Institute of Vegetative Anatomy, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Pharmacology, I.M. Sechenov First Moscow State Medical University of the Ministry of Healthcare of the Russian Federation (Sechenovskiy University), Moscow, Russia
| | - Sebastian Bachmann
- Institute of Vegetative Anatomy, Charité-Universitätsmedizin Berlin, Berlin, Germany
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20
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Tzamaloukas AH, Khitan ZJ, Glew RH, Roumelioti M, Rondon‐Berrios H, Elisaf MS, Raj DS, Owen J, Sun Y, Siamopoulos KC, Rohrscheib M, Ing TS, Murata GH, Shapiro JI, Malhotra D. Serum Sodium Concentration and Tonicity in Hyperglycemic Crises: Major Influences and Treatment Implications. J Am Heart Assoc 2019; 8:e011786. [PMID: 31549572 PMCID: PMC6806024 DOI: 10.1161/jaha.118.011786] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 06/04/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Antonios H. Tzamaloukas
- Raymond G. Murphy Veterans Affairs Medical CenterAlbuquerqueNM
- University of New Mexico School of MedicineAlbuquerqueNM
| | - Zeid J. Khitan
- Joan C. Edwards School of MedicineMarshall UniversityHuntingtonWV
| | - Robert H. Glew
- University of New Mexico School of MedicineAlbuquerqueNM
| | | | | | | | - Dominic S. Raj
- George Washington University School of MedicineWashingtonDC
| | - Jonathan Owen
- University of New Mexico School of MedicineAlbuquerqueNM
| | - Yijuan Sun
- Raymond G. Murphy Veterans Affairs Medical CenterAlbuquerqueNM
- University of New Mexico School of MedicineAlbuquerqueNM
| | | | | | - Todd S. Ing
- Stritch School of MedicineLoyola University ChicagoMaywoodIL
| | - Glen H. Murata
- Raymond G. Murphy Veterans Affairs Medical CenterAlbuquerqueNM
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21
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Gallo de Moraes A, Surani S. Effects of diabetic ketoacidosis in the respiratory system. World J Diabetes 2019; 10:16-22. [PMID: 30697367 PMCID: PMC6347653 DOI: 10.4239/wjd.v10.i1.16] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/08/2018] [Accepted: 12/13/2018] [Indexed: 02/05/2023] Open
Abstract
Diabetes affects approximately 30 million persons in the United States. Diabetes ketoacidosis is one of the most serious and acute complications of diabetes. At the time of presentation and during treatment of diabetic ketoacidosis (DKA), several metabolic and electrolyte derangements can ultimately result in respiratory compromise. Most commonly, hypokalemia, hypomagnesemia and hypophosphatemia can eventually lead to respiratory muscles failure. Furthermore, tachypnea, hyperpnea and more severely, Kussmaul breathing pattern can develop. Also, hydrostatic and non-hydrostatic pulmonary edema can occur secondary to volume shifts into the extracellular space and secondary to increased permeability of the pulmonary capillaries. The presence of respiratory failure in patients with DKA is associated with higher morbidity and mortality. Being familiar with the causes of respiratory compromise in DKA, and how to treat them, may represent better outcomes for patients with DKA.
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Affiliation(s)
- Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Salim Surani
- Division of Pulmonary, Critical Care and Sleep Medicine, Texas A and M University, Corpus Christy, TX 78412, United States
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22
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Usman A, Makmor Bakry M, Mustafa N, Rehman IU, Bukhsh A, Lee SWH, Khan TM. Correlation of acidosis-adjusted potassium level and cardiovascular outcomes in diabetic ketoacidosis: a systematic review. Diabetes Metab Syndr Obes 2019; 12:1323-1338. [PMID: 31496770 PMCID: PMC6689561 DOI: 10.2147/dmso.s208492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/05/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND 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.
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Affiliation(s)
- Atif Usman
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Correspondence: Atif UsmanSchool of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan47500, Bandar Sunway, Selangor, MalaysiaEmail
| | - Mohd Makmor Bakry
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Norlaila Mustafa
- Department of Endocrinology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Inayat Ur Rehman
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Pakistan
| | - Allah Bukhsh
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
- Asian 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, Malaysia
- Tahir Mehmood KhanSchool of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan47500, Bandar Sunway, Selangor, MalaysiaEmail ;
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23
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Al Hazmi A, Manning S. Limb Ischemia in a Patient with Hyperosmolar Hyperglycemic State. Clin Pract Cases Emerg Med 2018; 2:348-352. [PMID: 30443624 PMCID: PMC6230346 DOI: 10.5811/cpcem.2018.9.39920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 12/02/2022] Open
Abstract
A 61-year-old male with a recent diagnosis of pemphigus vulgaris was brought to the emergency department for altered mental status. He had recently started taking prednisone to manage his autoimmune disease and had a progressive decline in his mental status along with decreased oral intake. Evaluation revealed hyperosmolar hyperglycemic state (HHS) and occlusive arterial thrombosis, a rare but known complication of HHS. He was resuscitated aggressively with intravenous fluids, insulin, and heparin and admitted to the intensive care unit. Emergency physicians should remain vigilant for ischemic complications in patients with HHS. Early recognition and treatment can reduce the morbidity and mortality associated with this endocrine emergency.
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Affiliation(s)
- Ahmed Al Hazmi
- University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Sara Manning
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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24
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 400] [Impact Index Per Article: 57.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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25
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Sharma E, Dahal S, Sharma P, Ghimire DK, Dahal S. A Case of Pseudoinfarction Pattern in Diabetic Ketoacidosis: A Diagnostic and Therapeutic Dilemma. Cardiol Res 2018; 9:250-252. [PMID: 30116454 PMCID: PMC6089466 DOI: 10.14740/cr747w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/23/2018] [Indexed: 11/21/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is regularly associated with hyperkalemia that results in well-described changes on the electrocardiogram (EKG). However, ST-segment elevations on EKG mimicking acute myocardial infarction have rarely been described in the setting of DKA. Here we present a case of a 43-year-old male with DKA who had pseudoinfarction pattern of ST-segment elevation on EKG that resolved with treatment of DKA and discuss the diagnostic and therapeutic dilemma around the condition.
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Affiliation(s)
- Eliza Sharma
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Suyash Dahal
- Department of Medicine, KIST Medical College and Teaching Hospital, Lalitpur, Nepal
| | - Pratibha Sharma
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Dipesh Kc Ghimire
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Sumit Dahal
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
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26
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Song R, Cao S. Prediabetes Directly Deteriorates into Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome Triggered by Acute Pancreatitis: A Case Report Illustrating a "Chicken and Egg" Paradigm in Ketosis-Prone Diabetes. Diabetes Ther 2018; 9:1377-1383. [PMID: 29600506 PMCID: PMC5984920 DOI: 10.1007/s13300-018-0417-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Diabetic crises occur most often in patients with type 1 diabetes and occasionally in type 2 diabetes, especially under stressful conditions. However, a diabetic crisis occurring directly from prediabetes is an unusual phenomenon. CASE REPORT A 45-year-old woman presented with postprandial left upper quadrant abdominal pain, nausea, and vomiting. She had a past medical history of prediabetes with impaired fasting glucose and HbA1c 6.4%. On admission, routine laboratory tests showed high anion gap metabolic acidosis (pH 6.92), anion gap 41 mmol/L, blood glucose 931 mg/dL, beta-hydroxybutyrate 28 mmol/L, and calculated effective osmolarity 322 mOsm/kg; she was diagnosed with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS), and DKA-related abdominal pain. Later, the patient was found to have elevated lipase and amylase, and diagnosed with acute pancreatitis. Since DKA can induce abdominal pain and nonspecific lipase elevation, both of which are characteristics of acute pancreatitis, while acute pancreatitis can conversely trigger DKA, there exists a "chicken and egg" paradigm. Therefore, the differential diagnosis is discussed. CONCLUSION It is important to differentiate DKA from concomitant causes of abdominal pain to avoid missing the underlying etiology, which can be the trigger for DKA. During diabetic crises, treating the underlying trigger is just as important as managing metabolic derangements in order to achieve favorable outcomes; meanwhile, managing acute pancreatitis-associated hyperglycemia can promote recovery. Additionally, diabetic crisis that directly evolves from prediabetes illustrates an atypical form of diabetes called ketosis-prone diabetes; we briefly discuss its clinical characteristics, classification, and follow-up.
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Affiliation(s)
- Runbo Song
- Department of General Surgery, Shijiazhuang 3rd Hospital, 15 Tiyu South Street, Changan District, Shijiazhuang, 050000, Hebei, China
| | - Shanjin Cao
- Department of Hospitalist, St. Anne's Hospital, 795 Middle Street, Fall River, MA, 02721, USA.
- PrimaCARE, P.C., 277 Pleasant Street, Fall River, MA, 02721, USA.
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Gibb J, Xu Z, Rohrscheib M, Tzamaloukas AH. Hyperglycemic Crisis in an Anuric Peritoneal Dialysis Patient with Profound and Symptomatic Hypertonicity. Cureus 2018; 10:e2566. [PMID: 29974021 PMCID: PMC6029734 DOI: 10.7759/cureus.2566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
An anuric peritoneal dialysis patient with diabetes mellitus, congestive heart failure, and anasarca developed severe hyperglycemia with hypertonicity causing profound neurological manifestations after prolonged and continuous use of hypertonic (4.25%) dextrose dialysate. She expired with hypotensive shock from a new myocardial infarction soon after completion of treatment with insulin infusion. The degree of the presenting hypertonicity far exceeded the value expected from the degree of hyperglycemia. We identified prolonged peritoneal dialysis with hypertonic solutions and profound extracellular volume expansion as the causes of the excessive hypertonicity. Hyperglycemia developing in diabetic patients treated for anasarca by peritoneal dialysis after continuous use of hypertonic dextrose dialysate is associated with the risk of excessive hypertonicity with severe clinical manifestations.
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Affiliation(s)
- James Gibb
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Zhi Xu
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Mark Rohrscheib
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, USA
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Usman A. Initial Potassium Replacement in Diabetic Ketoacidosis: The Unnoticed Area of Gap. Front Endocrinol (Lausanne) 2018; 9:109. [PMID: 29619008 PMCID: PMC5871863 DOI: 10.3389/fendo.2018.00109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Atif Usman
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
- *Correspondence: Atif Usman,
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Abstract
We present the case of a 16-year-old boy who presented with fatigue, polyuria, and polydipsia while on chemotherapy for his relapsed acute lymphoblastic leukemia (ALL). Blood gas examination confirmed the diagnosis of hyperosmolar hyperglycemic state. The etiology for his hyperglycemia was most likely a result of oral glucocorticoid therapy combined with asparaginase therapy-both are a cornerstone of induction chemotherapy for ALL. The patient was aggressively rehydrated with saline, and medications were administered to correct his hyperkalemia. He was then slowly brought to euglycemia with a continuous infusion of insulin. Although hyperosmolar hyperglycemic state is rare during the treatment of ALL, frontline providers should be aware of this diagnosis because of the significant risk of hypovolemic shock and death if correction of hyperglycemia occurs prior to complete fluid resuscitation.
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Yamada H, Funazaki S, Kakei M, Hara K, Ishikawa SE. Diabetic ketoacidosis producing extreme hyperkalemia in a patient with type 1 diabetes on hemodialysis. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170068. [PMID: 28924484 PMCID: PMC5592707 DOI: 10.1530/edm-17-0068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 01/11/2023] Open
Abstract
Diabetic ketoacidosis (DKA) is a critical complication of type 1 diabetes associated with water and electrolyte disorders. Here, we report a case of DKA with extreme hyperkalemia (9.0 mEq/L) in a patient with type 1 diabetes on hemodialysis. He had a left frontal cerebral infarction resulting in inability to manage his continuous subcutaneous insulin infusion pump. Electrocardiography showed typical changes of hyperkalemia, including absent P waves, prolonged QRS interval and tented T waves. There was no evidence of total body water deficit. After starting insulin and rapid hemodialysis, the serum potassium level was normalized. Although DKA may present with hypokalemia, rapid hemodialysis may be necessary to resolve severe hyperkalemia in a patient with renal failure.
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Affiliation(s)
- Hodaka Yamada
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shunsuke Funazaki
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masafumi Kakei
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuo Hara
- Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - San-E Ishikawa
- Division of Endocrinology and Metabolism, International University of Health and Welfare Hospital, Nasushiobara, Japan
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Abstract
PURPOSE OF REVIEW Hyperglycemia in the emergency department (ED) is being recognized as a public health problem and presents a clinical challenge. This review critically summarizes available evidence on the burden, etiology, diagnosis, and practical management strategies for hyperglycemia in the ED. RECENT FINDINGS Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are hyperglycemic emergencies that commonly present to the ED. However, the most common form of hyperglycemia in ED is associated with non-hyperglycemic medical emergencies. The presence of hyperglycemia increases the mortality and morbidity associated with the primary condition. The related hospital admission rates and costs are also elevated. The frequency of DKA or HHS related mortality and morbidity has remained high over the last decade. However, attempts have been made to improve management of all hyperglycemia in the ED. Evidence suggests that better management of hyperglycemia in the ED with proper follow-up improves clinical outcomes and prevents readmission. Optimization of the hyperglycemia management in the ED may improve clinical outcomes. However, more clinical trial data on the outcomes and cost-effectiveness of various management strategies or protocols are needed.
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Affiliation(s)
- Justin B Echouffo-Tcheugui
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02215, USA
| | - Rajesh Garg
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02215, USA.
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Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am 2017; 101:587-606. [PMID: 28372715 PMCID: PMC6535398 DOI: 10.1016/j.mcna.2016.12.011] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.
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Affiliation(s)
- Maya Fayfman
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Francisco J Pasquel
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA.
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Bourgon S, Diel de Amorim M, Miller S, Montanholi Y. Associations of blood parameters with age, feed efficiency and sampling routine in young beef bulls. Livest Sci 2017. [DOI: 10.1016/j.livsci.2016.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Kamel KS, Schreiber M, Carlotti APCP, Halperin ML. Approach to the Treatment of Diabetic Ketoacidosis. Am J Kidney Dis 2016; 68:967-972. [PMID: 27599629 DOI: 10.1053/j.ajkd.2016.05.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 05/13/2016] [Indexed: 01/11/2023]
Abstract
Diabetic ketoacidosis (DKA), a common cause of severe metabolic acidosis, remains a life-threatening condition due to complications of both the disease and its treatment. This Acid-Base and Electrolyte Teaching Case discusses DKA management, emphasizing complications of treatment. Because cerebral edema is the most common cause of mortality and morbidity, especially in children with DKA, we emphasize its pathophysiology and implications for therapy. The risk for cerebral edema may be minimized by avoiding a bolus of insulin, excessive saline resuscitation, and a decrease in effective plasma osmolality early in treatment. A goal of fluid therapy is to lower muscle venous Pco2 to ensure effective removal of hydrogen ions by bicarbonate buffer in muscle and diminish the binding of hydrogen ions to intracellular proteins in vital organs (such as the brain). In patients with DKA and a relatively low plasma potassium level, insulin administration may cause hypokalemia and cardiac arrhythmias. It is suggested in these cases to temporarily delay insulin administration and first administer potassium chloride intravenously to bring the plasma potassium level close to 4mmol/L. Sodium bicarbonate administration in adult patients should be individualized. We suggest it be considered in a subset of patients with moderately severe acidemia (pH<7.20 and plasma bicarbonate level < 12mmol/L) who are at risk for worsening acidemia, particularly if hemodynamically unstable. Sodium bicarbonate should not be administered to children with DKA, except if acidemia is very severe and hemodynamic instability is refractory to saline administration.
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Affiliation(s)
- Kamel S Kamel
- Renal Division, St Michael's Hospital and University of Toronto, Ontario, Canada; Keenan Research Center in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
| | - Martin Schreiber
- Renal Division, St Michael's Hospital and University of Toronto, Ontario, Canada
| | - Ana P C P Carlotti
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Mitchell L Halperin
- Renal Division, St Michael's Hospital and University of Toronto, Ontario, Canada; Keenan Research Center in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
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Abstract
Hyperkalemia can be a life-threatening event due to the risk of potentially fatal arrhythmias. Hyperkalemia has been reported in 1.3% (serum potassium greater than 6.0 mEq/mL) to 10% (greater than 5.3 mEq/mL) of patients. Hyperkalemia secondary to beta-adrenergic receptor blockade can occur in 1% to 5% of patients and is more likely to occur in non-cardio-selective beta-blockers versus cardio-selective beta-blockers. This case report describes hyperkalemia in a 72-year-old female with diabetes and underlying chronic renal failure receiving metoprolol. Chronically, potassium balance is maintained by the kidney. In acute situations, such as a larger than normal potassium load, both the kidney and the body's cells react to maintain normal potassium levels. Generally, hyperkalemia occurs secondary to 3 mechanisms: excessive potassium intake, disturbed cellular uptake of potassium, or impaired renal excretion of potassium. Beta-blockers, when used in patients with comorbidities such as renal dysfunction or insulin insufficiency, can potentially cause hyperkalemia. As demonstrated in this case report, hyperkalemia can occur in patients treated with cardio-selective beta-blockers with concurrent risk factors. Health care professionals need to be aware of this potentially life-threatening event to effectively prevent occurrences of beta-blocker-induced hyperkalemia.
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Affiliation(s)
- John Hawboldt
- School of Pharmacy at Memorial University of Newfoundland, St. John's, NL,
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Umpierrez G, Korytkowski M. Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nat Rev Endocrinol 2016; 12:222-32. [PMID: 26893262 DOI: 10.1038/nrendo.2016.15] [Citation(s) in RCA: 283] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and hypoglycaemia are serious complications of diabetes mellitus that require prompt recognition, diagnosis and treatment. DKA and HHS are characterized by insulinopaenia and severe hyperglycaemia; clinically, these two conditions differ only by the degree of dehydration and the severity of metabolic acidosis. The overall mortality recorded among children and adults with DKA is <1%. Mortality among patients with HHS is ~10-fold higher than that associated with DKA. The prognosis and outcome of patients with DKA or HHS are determined by the severity of dehydration, the presence of comorbidities and age >60 years. The estimated annual cost of hospital treatment for patients experiencing hyperglycaemic crises in the USA exceeds US$2 billion. Hypoglycaemia is a frequent and serious adverse effect of antidiabetic therapy that is associated with both immediate and delayed adverse clinical outcomes, as well as increased economic costs. Inpatients who develop hypoglycaemia are likely to experience a long duration of hospital stay and increased mortality. This Review describes the clinical presentation, precipitating causes, diagnosis and acute management of these diabetic emergencies, including a discussion of practical strategies for their prevention.
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Affiliation(s)
- Guillermo Umpierrez
- Division of Endocrinology and Metabolism, Emory University School of Medicine, 49 Jesse Hill Jr Drive, Atlanta, Georgia 30303, USA
| | - Mary Korytkowski
- Division of Endocrinology and Metabolism, University of Pittsburgh, 3601 Fifth Avenue, Suite 560, Pittsburgh, Pennsylvania 15213, USA
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Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism 2016; 65:507-21. [PMID: 26975543 DOI: 10.1016/j.metabol.2015.12.007] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/10/2015] [Accepted: 12/16/2015] [Indexed: 12/11/2022]
Abstract
The prognosis of diabetic ketoacidosis has undergone incredibly remarkable evolution since the discovery of insulin nearly a century ago. The incidence and economic burden of diabetic ketoacidosis have continued to rise but its mortality has decreased to less than 1% in good centers. Improved outcome is attributable to a better understanding of the pathophysiology of the disease and widespread application of treatment guidelines. In this review, we present the changes that have occurred over the years, highlighting the evidence behind the recommendations that have improved outcome. We begin with a discussion of the precipitants and pathogenesis of DKA as a prelude to understanding the rationale for the recommendations. A brief review of ketosis-prone type 2 diabetes, an update relating to the diagnosis of DKA and a future perspective are also provided.
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Affiliation(s)
- Ebenezer A Nyenwe
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 920 Madison Ave., Suite 300A, Memphis, TN 38163.
| | - Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 920 Madison Ave., Suite 300A, Memphis, TN 38163
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Talebi S, Ghobadi F, Cacacho A, Olatunde O, DeRobertis A, Pekler G, Visco F, Mushiyev S, Hassen GW. Looking at diabetic ketoacidosis through electrocardiogram window! Am J Emerg Med 2016; 34:263-5. [DOI: 10.1016/j.ajem.2015.10.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 09/16/2015] [Accepted: 10/14/2015] [Indexed: 10/22/2022] Open
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Konstantinov NK, Rohrscheib M, Agaba EI, Dorin RI, Murata GH, Tzamaloukas AH. Respiratory failure in diabetic ketoacidosis. World J Diabetes 2015; 6:1009-1023. [PMID: 26240698 PMCID: PMC4515441 DOI: 10.4239/wjd.v6.i8.1009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/08/2015] [Accepted: 05/27/2015] [Indexed: 02/05/2023] Open
Abstract
Respiratory failure complicating the course of diabetic ketoacidosis (DKA) is a source of increased morbidity and mortality. Detection of respiratory failure in DKA requires focused clinical monitoring, careful interpretation of arterial blood gases, and investigation for conditions that can affect adversely the respiration. Conditions that compromise respiratory function caused by DKA can be detected at presentation but are usually more prevalent during treatment. These conditions include deficits of potassium, magnesium and phosphate and hydrostatic or non-hydrostatic pulmonary edema. Conditions not caused by DKA that can worsen respiratory function under the added stress of DKA include infections of the respiratory system, pre-existing respiratory or neuromuscular disease and miscellaneous other conditions. Prompt recognition and management of the conditions that can lead to respiratory failure in DKA may prevent respiratory failure and improve mortality from DKA.
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Kim HW, Lee DH, Lee SA, Koh G. A relationship between serum potassium concentration and insulin resistance in patients with type 2 diabetes mellitus. Int Urol Nephrol 2015; 47:991-9. [PMID: 25966806 DOI: 10.1007/s11255-015-1001-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 04/26/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE In patients with type 2 diabetes mellitus (DM), insulin-stimulated glucose uptake is impaired. However, the relationship between serum potassium concentration and insulin resistance is poorly defined. This study aimed to investigate the association between serum potassium concentration and insulin resistance in these patients. METHODS Between April 2009 and October 2012, 180 patients with type 2 DM were analyzed. Insulin resistance was estimated using the homeostasis model and assessment (HOMA) index; resistance was defined as an index value of >2. The association between serum potassium concentration and insulin resistance was analyzed using linear regression methods. The incidence of hyperkalemia was also evaluated during follow-up. RESULTS Mean serum potassium concentration was 4.12 ± 0.47 mEq/l. The median HOMA index score was 2.1 (interquartile range 1.1-3.4). When the patients were compared based on insulin resistance, serum potassium concentration was higher in the patients with insulin resistance compared with the patients without (4.25 ± 0.48 vs. 4.09 ± 0.44 mEq/l, p = 0.015). The variables found to be the determinants of serum potassium concentration included female, renal function, serum sodium level, log aldosterone-to-plasma renin activity ratio, glycosylated hemoglobin, and log HOMA index. Over a mean follow-up period of 2.6 ± 1.1 years, 37 of 180 patients (21 %) experienced episodic hyperkalemia. Patients with insulin resistance experienced episodic hyperkalemia more frequently than those without. CONCLUSIONS Serum potassium concentration is likely to be increased in the patients with poorly controlled type 2 DM with insulin resistance than in those without insulin resistance.
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Affiliation(s)
- Hyun Woo Kim
- Department of Internal Medicine, Jeju National University School of Medicine, 102 Jejudaehakno, Jeju City, Jeju, 690-756, Republic of Korea,
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Gómez Rivera N, García Zárate MG, Fonseca Chon I, Gómez Figueroa CO, Gómez Jiménez IA, Villalobos García L. [Diabetic ketoacidosis in children: hospital experience. A 15-year retrospective study]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2015; 72:313-317. [PMID: 29421529 DOI: 10.1016/j.bmhimx.2015.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 09/11/2015] [Accepted: 09/13/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is one of the major complications of diabetes mellitus (DM). The objective of this report was to highlight the clinical and laboratory importance in the treatment of patients with DKA during a 15-year period treated at the Hospital Infantil del Estado de Sonora (HIES). METHODS We retrospectively reviewed 140 patients with episodes of DKA to report clinical and laboratory features, mortality, and treatment with HIES protocol. RESULTS Mortality was 0%. Using descriptive statistics we observed minimal complications without neurologic sequelae in three patients with cerebral edema. CONCLUSIONS The HIES protocol is a practical and effective electrolyte and acid-base treatment for DKA.
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Akinlade AT, Ogbera AO, Fasanmade OA, Olamoyegun MA. Serum C-peptide assay of patients with hyperglycemic emergencies at the Lagos State University Teaching Hospital (LASUTH), Ikeja. Int Arch Med 2014; 7:50. [PMID: 25945127 PMCID: PMC4413546 DOI: 10.1186/1755-7682-7-50] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 11/11/2014] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION HE are common acute complications of diabetes mellitus (DM) and include diabetic ketoacidosis (DKA), normo-osmolar hyperglycemic state (NHS) and hyperosmolar hyperglycemic state (HHS). They contribute a lot to the mortality and morbidity of DM. The clinical features include dehydration, hyperglycemia, altered mental status and ketosis. The basic mechanism of HE is a reduction in the net effective action of circulating insulin, resulting in hyperglycemia and ketonemia (in DKA) causing osmotic diuresis and electrolytes loss. Infection is a common precipitating factor. Measurement of serum C-peptide provides an accurate assessment of residual β-cell function and is a marker of insulin secretion in DM patients. AIM AND OBJECTIVES To assess the level of pancreatic beta cell function in HE patients, using the serum C-peptide. METHODOLOGY The biodata and clinical characteristics of the 99 subjects were collated using a questionnaire. All subjects had their serum C-peptide, glucose, electrolytes, urea, creatinine levels, urine ketones determined at admission. Results of statistical analysis were expressed as mean ± standard deviation (SD). A p value <0.05 was regarded statistically significant. Correlation between levels of serum C-peptide and admission blood glucose levels and the duration of DM respectively was done. RESULTS The mean age of the subjects was 51 (SD ± 16) years and comparable in both sexes. Mean duration of DM was 6.3 (SD ± 7.1) years, with 35% newly diagnosed at admission. The types of HE in this study are: DKA (24.7%), NHS (36.1%), and HHS (39.2%). Mean blood glucose in this study was 685 mg/dL, significantly highest in HHS and lowest in NHS. Mean serum C-peptide level was 1.6 ng/dL. It was 0.9 ng/dL in subjects with DKA and NHS while 2.7 ng/dL in HHS (p>0.05). Main precipitating factors were poor drug compliance, new-onset of DM and infection. CONCLUSION Most (70%) of subjects had poor pancreatic beta cell function, this may be a contributory factor to developing HE. Most subjects with high C-peptide levels had HHS.
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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Corwell B, Knight B, Olivieri L, Willis GC. Current Diagnosis and Treatment of Hyperglycemic Emergencies. Emerg Med Clin North Am 2014; 32:437-52. [DOI: 10.1016/j.emc.2014.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Regmi A, Konstantinov NK, Agaba EI, Rohrscheib M, Dorin RI, Tzamaloukas AH. Respiratory Failure in the Course of Treatment of Diabetic Ketoacidosis. Clin Diabetes 2014; 32:28-31. [PMID: 26246676 PMCID: PMC4521429 DOI: 10.2337/diaclin.32.1.28] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) are potentially fatal hyperglycemic crises that occur as acute complications of uncontrolled diabetes mellitus. The authors provide a review of the current epidemiology, precipitating factors, pathogenesis, clinical presentation, evaluation, and treatment of DKA and HHS. The discovery of insulin in 1921 changed the life expectancy of patients with diabetes mellitus dramatically. Today, almost a century later, DKA and HHS remain significant causes of morbidity and mortality across different countries, ages, races, and socioeconomic groups and a significant economic burden for society.
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Affiliation(s)
- Jelena Maletkovic
- Department of Endocrinology, UCLA School of Medicine, Gonda Diabetes Center, 200 UCLA Medical Plaza, Suite 530, Los Angeles, CA 90095, USA.
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Abdulaziz S, Dabbagh O, Al Daker MO, Hassan I. Hypokalaemia and refractory asystole complicating diabetic ketoacidosis, lessons for prevention. BMJ Case Rep 2012; 2012:bcr-2012-007312. [PMID: 23220438 DOI: 10.1136/bcr-2012-007312] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We report a unique case of diabetic ketoacidosis in which a relatively low potassium level on admission was associated with consequent life-threatening and refractory arrhythmia secondary to inappropriate use of intravenous insulin and bicarbonate therapy. The latter was reversed by rapid bolus potassium injection. Although we do not advocate this approach in every case, we emphasise that a bolus injection of potassium may be life saving in such cases. The lessons from this case have led to multidisciplinary meetings and modification of the institute's diabetic ketoacidosis clinical pathway.
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Affiliation(s)
- Salman Abdulaziz
- Department of Internal Medicine, King Abdulaziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia.
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Abstract
Diabetic ketoacidosis (DKA) is caused by absolute or relative lack of insulin. Lack of insulin leads to hyperglycemia, ketonemia, and acidosis. Prevalence of DKA at diagnosis of type 1 diabetes (T1D) varies around the world from 18 % to 84 %. Incidence of recurrent DKA is higher among females, insulin pump users, those with a history of psychiatric or eating disorder, and suboptimal socioeconomic circumstances. DKA is the most common cause of death in children with T1D. Children with DKA should be treated in experienced centers. Initial bolus of 10-20 mL/kg 0.9 % saline is followed by 0.45 %-0.9 % saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours. The prevention of DKA at diagnosis of diabetes can be achieved by an intensive community intervention and education of health care providers to raise awareness. Prevention of recurrent DKA requires continuous patient education and access to diabetes programs and telephone services.
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Affiliation(s)
- Arleta Rewers
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado Denver, School of Medicine, Aurora, CO 80045, USA.
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Koves IH, Pihoker C. Pediatric diabetic ketoacidosis management in the era of standardization. Expert Rev Endocrinol Metab 2012; 7:433-443. [PMID: 30754163 DOI: 10.1586/eem.12.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Up to 70% of children with new-onset Type 1 diabetes mellitus (T1DM) present with diabetic ketoacidosis (DKA), with most cases initially assessed by their primary care provider. DKA is the most common cause of death in children with T1DM, mainly related to cerebral edema that occurs at a frequency of 0.15-4.6%. Early recognition of DKA can be improved by increasing the awareness of early clinical symptoms such as enuresis, polyuria and polydipsia. Clinical acumen paired with early assessment of patients with suspected T1DM and known T1DM, particularly if risk factors for DKA are present, can prevent serious complications and fatal outcomes. Urgent referral to specialist centers for suspected new-onset T1DM/DKA is required. A standardized approach is recommended to be followed to ensure successful initial management of DKA, both in the nonspecialist setting before transfer and in the more specialized hospital setting. This article outlines such a management approach.
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Affiliation(s)
- Ildiko H Koves
- b Seattle Children's Hospital, Division of Endocrinology and Diabetes, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| | - Catherine Pihoker
- a Seattle Children's Hospital, Division of Endocrinology and Diabetes, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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Rachoin JS, Cerceo EA. Four nephrology myths debunked. J Hosp Med 2011; 6:E1-5. [PMID: 21661096 DOI: 10.1002/jhm.703] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 02/25/2010] [Accepted: 03/02/2010] [Indexed: 11/08/2022]
Abstract
There are many controversial topics relating to renal disease in hospitalized patients. The aim of this review is to shed light on some important and often debated issues. Hypothyroidism, unlike myxedema, is not a cause of hyponatremia (although it can be sometimes seen in conjunction with the latter) and additional investigations should be done to determine its etiology. Sodium bicarbonate is effective for treatment of hyperkalemia primarily by enhancing renal potassium elimination rather than by translocating potassium into cells. Acetaminophen can be a cause of metabolic acidosis by causing 5-oxoprolinuria. Furosemide (and sulfa containing diuretics) can safely be used in patients with an allergy to sulfa-containing antibiotics (SCA).
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Affiliation(s)
- Jean-Sebastien Rachoin
- Department of Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Cooper University Hospital, Camden, New Jersey, USA.
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