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Acute Kidney Injury In Dka

Outcome Of Acute Renal Failure In Children With Diabetic Keto Acidosis (dka)

Outcome Of Acute Renal Failure In Children With Diabetic Keto Acidosis (dka)

OUTCOME OF ACUTE RENAL FAILURE IN CHILDREN WITH DIABETIC KETO ACIDOSIS (DKA) Poovazhagi V, Prabha Senguttuvan, Padmaraj R Diabetic Clinic, Institute of Child Health and Hospital for Children, Chennai Address for Correspondence Dr V Poovazhagi, 8/11 Manjolai Street, Kalaimagal Nagar, Ekkaduthangal, Chennai. 600 032, India. Email [email protected] Abstract The presentation and outcome of acute renal failure in children with diabetic ketoacidosis (DKA) were analyzed. Of the 130 DKA episodes treated at the Pediatric Intensive Care Unit (PICU), 15 children (11.5%) had renal failure. Sepsis and shock were the common etiological factors. Mortality in ARF complicating DKA was 40%. Persistent acidosis requiring bicarbonate therapy, reduction in intravenous fluid volume, reduced dose of insulin and peritoneal dialysis were the modifications in the treatment for this life-threatening complication. Keywords Acute Renal failure, DKA, infections, shock Introduction Cerebral edema is a life threatening complication of diabetic ketoacidosis (DKA), other complications include dyselectrolytemia, acute respiratory distress syndrome (ARDS), pulmonary edema and renal failure. Chronic renal failure due to diabetic nephropathy and its presentation with DKA is encountered in adults. But children with new onset diabetes mellitus (DM) or known diabetic children presenting with acute renal failure (ARF) is rare. Literature reveals few case reports of DKA with renal failure. (1,2,3) Reported mortality in ARF complicating DKA is about 50%. (1) We are presenting a series of children with DKA and renal failure. Methods & Materials This retrospective study was undertaken to evaluate the outcome of children with ARF in DKA from January 2006 to August 2010 in 130 children who presented with DKA. None w Continue reading >>

Incidence And Characteristics Of Acute Kidney Injury In Severe Diabetic Ketoacidosis

Incidence And Characteristics Of Acute Kidney Injury In Severe Diabetic Ketoacidosis

Abstract Acute kidney injury is a classical complication of diabetic ketoacidosis. However, to the best of our knowledge, no study has reported the incidence and characteristics of acute kidney injury since the consensus definition was issued. Retrospective study of all cases of severe diabetic ketoacidosis hospitalised consecutively in a medical surgical tertiary ICU during 10 years. Patients were dichotomised in with AKI and without AKI on admission according to the RIFLE classification. Clinical and biological parameters were compared in these populations. Risk factors of presenting AKI on admission were searched for. Results Ninety-four patients were included in the study. According to the RIFLE criteria, 47 patients (50%) presented acute kidney injury on admission; most of them were in the risk class (51%). At 12 and 24 hours, the percentage of AKI patients decreased to 26% and 27% respectively. During the first 24 hours, 3 patients needed renal replacement therapy. Acute renal failure on admission was associated with a more advanced age, SAPS 2 and more severe biological impairments. Treatments were not different between groups except for insulin infusion. Logistic regression found 3 risk factors of presenting AKI on admission: age (odds ratio 1.060 [1.020–1.100], p<0.01), blood glucose (odds ratio 1.101 [1.039–1.166], p<0.01) and serum protein (odds ratio 0.928 [0.865–0.997], p = 0.04). Acute kidney injury is frequently associated with severe diabetic ketoacidosis on admission in ICU. Most of the time, this AKI is transient and characterised by a volume-responsiveness to fluid infusion used in DKA treatment. Age, blood glucose and serum protein are associated to the occurrence of AKI on ICU admission. Figures Citation: Orban J-C, Maizière E-M, Ghaddab A, V Continue reading >>

Acute Kidney Injury As A Severe Complication Of Diabetic Ketoacidosis

Acute Kidney Injury As A Severe Complication Of Diabetic Ketoacidosis

Background: Diabetic ketoacidosis (DKA) in children and young adults carries significant morbidity and mortality relating to complications such as cerebral oedema. Acute kidney injury (AKI) is a rare but potentially fatal complication of DKA. We present three cases of DKA complicated by AKI. Case 1: A 9-year-old girl presented with severe DKA at diagnosis. She was treated with intravenous fluids and insulin as per protocol. She had oliguria and haematuria 36 h after admission. She was hypertensive with evidence of enlarged kidneys on ultrasound (USS). She was transferred to the renal unit where she needed two cycles of hemodialysis before making full recovery. Case 2: A 14-year-old girl presented with severe DKA and altered consciousness at diagnosis. She developed oliguria 24 h after starting treatment for DKA. USS of abdomen showed enlarged kidneys. Her renal function improved with haemofiltration and recovered fully by 1 week. Case 3: 17-year-old girl with poorly controlled type 1 diabetes presented with severe DKA. She showed evidence of AKI with very high plasma creatinine, oliguria and low plasma phosphate. She was managed conservatively with individualised fluid plan and phosphate supplementation with recovery in 7 days. Conclusion: Patients with severe DKA can develop AKI due to a number of possible causes, hypovolaemia being the most likely primary cause. Appropriate management of hypovolemia and electrolyte disturbance in these patients can be very challenging. These cases highlight the importance of early recognition of AKI (rising plasma creatinine, oliguria, haematuria) and discussion with paediatric nephrologist to formulate individualised fluid therapy in order to prevent deterioration in renal function. It is uncertain if recent modification in fluid man Continue reading >>

Aki Seen In 64% Of Children Hospitalized With Diabetic Ketoacidosis

Aki Seen In 64% Of Children Hospitalized With Diabetic Ketoacidosis

A high proportion of children with type 1 diabetes who are hospitalized for diabetic ketoacidosis (DKA) develop acute kidney injury (AKI), according to results from a study. Researchers reviewing records from a Canadian hospital found that in a cohort of 165 children hospitalized for DKA during a 5-year period (2008-2013), 64% developed the complication. Severe forms of AKI (stage 2 or 3) were common, representing 45% and 20%, respectively, of children with AKI. Two patients in the cohort required dialysis. In their research published online March 13 in JAMA Pediatrics, Brenden E. Hursh, MD, and his colleagues at the University of British Columbia and the British Columbia Children’s Hospital, both in Vancouver, noted that AKI rates among hospitalized children had not been systematically studied before. “We hypothesized that, because DKA is associated with both volume depletion and conservative fluid administration upon presentation, these children are potentially at high risk for AKI, above the level of risk expected by the rare reported cases in the literature,” Dr. Hursh and his colleagues wrote (JAMA Pediatr. 2017 Mar 13. doi: 10.1001/jamapediatrics.2017.0020). The investigators found that lower serum bicarbonate levels and elevated heart rates were indeed associated with increased risk of severe AKI. Serum bicarbonate level of less than 10 mEq/L was associated with a fivefold increase in the odds of severe (stage 2 or 3) AKI (adjusted odds ratio, 5.22; 95% confidence interval, 1.35-20.22). Each increase of 5 bpm in initial heart rate was associated with a 22% increase in the odds of severe AKI (aOR, 1.22; 95% CI, 1.07-1.39). Dr. Hursh and his colleagues defined AKI using serum creatinine values. As baseline values prior to hospital admission were not available Continue reading >>

Acute Kidney Injury Is A Frequent Complication Of Pediatric Diabetic Ketoacidosis

Acute Kidney Injury Is A Frequent Complication Of Pediatric Diabetic Ketoacidosis

MedicalResearch.com Interview with: Constadina Panagiotopoulos, MD, FRCPC Department of Pediatrics, Endocrinology & Diabetes Unit British Columbia Children’s Hospital Vancouver, British Columbia, Canada MedicalResearch.com: What is the background for this study? Response: I decided to conduct this study after observing a few cases of severe acute kidney injury (AKI) in children hospitalized with diabetic ketoacidosis (DKA) (with two patients requiring dialysis) while on call in the 18 months prior to initiating the study. While caring for these patients, I scanned the literature and realized that aside from 2 published case reports, there had been no large-scale systematic studies assessing AKI in children with DKA. It immediately became apparent to me that managing patients with AKI and DKA was more challenging. On presentation to hospital, many of these children with DKA present quite volume depleted but fluid management is conservative because of the risk for cerebral edema. One of the most important management strategies for acute kidney injury in patients with DKA is early detection and correcting volume depletion in a timely manner to prevent further injury. I discussed my observations and these clinical cases with pediatric nephrologist and co-investigator Dr. Cherry Mammen, a pediatric AKI expert, and he confirmed my initial literature review findings. Thus, we decided to conduct this study to better understand the scope of the problem and any associated risk factors. MedicalResearch.com: What are the main findings? Response: We found that 64% of children hospitalized with DKA met criteria for acute kidney injury. Serum bicarbonate level < 10 mEq/L and an elevated heart rate were found to be associated with an increased risk of severe acute kidney injury. Medi Continue reading >>

Diabetic Ketoacidosis Increases Risk Of Acute Renal Failure In Pediatric Patients With Type 1 Diabetes

Diabetic Ketoacidosis Increases Risk Of Acute Renal Failure In Pediatric Patients With Type 1 Diabetes

Condition often under-recognized, yet preventable and treatable. Diabetic ketoacidosis (DKA) is a syndrome presenting in people with diabetes when insulin utilization is markedly diminished, whether via sudden increases in insulin requirements (most often due to acute illness) or sharp decreases in exogenous insulin administration (sudden cessation, for example). DKA is manifested as severe hyperglycemia, systemic acidosis, and severe dehydration due to rapidly increasing osmotic diuresis. This condition is especially worrisome in the pediatric diabetic population, as the resulting risk of renal injury often goes unrecognized at presentation. In 2014, the results of the SEARCH for Diabetes in Youth Study suggested that approximately 30% of pediatric (<18 y.o.) type 1 diabetes patients presented with DKA at initial diagnosis. Other studies have looked at the treatment of DKA in the pediatric population, and its effects on morbidity and mortality, but until now, none have attempted to correlate DKA and acute renal failure. The current issue of JAMA Pediatric presents a study looking at the incidence of acute kidney injury in pediatric patients hospitalized for DKA and attempts to show a correlation between the two events. This retrospective review collected data on pediatric T1D patients admitted to the British Columbia Children’s Hospital with DKA between September 2008 and December 2013. Patients with the above mentioned conditions and complete medical records during that period were included. The primary objective was to determine the proportion of eligible subjects who developed acute kidney injury (AKI). During the prescribed time frame, 211 children were hospitalized at BCCH with DKA. Of these, 165 admissions met criteria for the study. Demographically, 53.9% were Continue reading >>

Effect Of Recurrent Diabetic Ketoacidosis Episodes On The Severity Of Acute Kidney Injury In Pediatric Dka

Effect Of Recurrent Diabetic Ketoacidosis Episodes On The Severity Of Acute Kidney Injury In Pediatric Dka

Abstract: BACKGROUND Recurrent episodes of acute kidney injury (AKI) are strongly associated with incident chronic kidney disease (CKD) and progression of CKD. Impaired renal function with increased serum creatinine is typical of untreated DKA and is thought, in most cases, to be fully reversible once renal perfusion is restored by volume repletion. The incidence of AKI, as well as risk factors associated with the severity of AKI during DKA are not well described in children with type I diabetes (T1D). METHODS We conducted a retrospective cohort study of all children under 19 years old with known T1D presenting at our two tertiary pediatric intensive care units with DKA between August 2012 and August 2013. DKA was defined using ISPAD criteria. AKI was defined according to pRIFLE criteria which classify AKI based upon the magnitude of change in estimated glomerular filtration rate (eGFR): R (risk, eGFR decreased by 25%), I (injury, eGFR decreased by 50%), and F (failure, eGFR decreased by 75%). GFR was estimated using the modified Schwartz equation and change in eGFR was calculated from baseline values (or 100mL/min/1.73m2 for those without baseline values). RESULTS The median age of the 112 subjects was 13 years (interquartile range 11, 15). Mild, moderate and severe DKA was present in 29, 35 and 36 percent of patients, respectively. AKI occurred in 95% of cases at presentation: 2 (2%), 43 (38%) and 61 (55%) patients were classified into pRIFLE categories F, I and R, respectively. The median time to resolution of DKA was 9 hours (interquartile range 6, 14). Of the 67 subjects who had serum creatinine concentrations measured 20 hours after initiation of DKA treatment, AKI had not yet resolved in 14 (20%) children. Multiple linear regression analysis revealed DKA severity Continue reading >>

Children With Type 1 Diabetes At Risk Of Acute Kidney Injury Following Dka, Study Reports

Children With Type 1 Diabetes At Risk Of Acute Kidney Injury Following Dka, Study Reports

Children with type 1 diabetes who are hospitalised for diabetic ketoacidosis (DKA) are more likely to develop acute kidney injury (AKI), a new study finds. Acute kidney injury can increase the risk of chronic disease, and children with more severe DKA had a heightened risk of severe AKI. Researchers from University of British Columbia, Vancouver, Canada say this study is the first to show that acute kidney injury is a frequent complication in DKA in youngsters. A total of 165 youths with type 1 diabetes aged 18 years and younger were studied, all of whom had been admitted to hospital for DKA between 2008-2013. Sixty-four per cent developed acute kidney injury, and those with severe DKA were five times more likely to develop severe acute kidney injury. The study team hypothesise that acute kidney injury may be recognised less in pediatric DKA because children's weight and height are not considered when interpreting levels of serum creatinine, which increase with AKI. Senior author Dina Panagiotopoulos, MD, explained to Medscape Medical News: "From this study, we became aware that recognizing acute kidney injury is a challenge, because serum creatinine needs to be interpreted in the context of a child's height. "As a result of our findings, we are developing a quick reference card that provides clinicians with a formula utilising the child's height to determine what their expected normal baseline creatinine would be prior to illness." Panagiotopoulos and colleagues have also begun a second study to assess the long-term impact of acute kidney injury in children who have experienced DKA, and the subsequent risk for developing chronic kidney disease. The study has been published online in JAMA Pediatrics. Tweet Type 2 diabetes mellitus is a metabolic disorder that results in Continue reading >>

Original Article Clinical Outcomes Of Septic Patients With Diabetic Ketoacidosis Between 2004 And 2013 In A Tertiary Hospital In Taiwan

Original Article Clinical Outcomes Of Septic Patients With Diabetic Ketoacidosis Between 2004 And 2013 In A Tertiary Hospital In Taiwan

Infection is the most common predisposing factor for diabetic ketoacidosis (DKA); however, studies are rare that have investigated the clinical outcomes of septic patients with infection-precipitated DKA. A retrospective cohort study was conducted at a tertiary hospital from 2004 to 2013. Patients with DKA in whom the presence of a predisposing infection was confirmed were enrolled. Characteristics at initial presentation, primary infection sources, and causative microorganisms were compared between the nonacute kidney injury (non-AKI) group and acute kidney injury (AKI) group at each stage. Risk factors for the development of failure-stage AKI and its outcomes were also analyzed. One hundred and sixty DKA episodes were assessed. The most common infection sites were the urinary and respiratory tracts. The leading causative microorganism was Escherichia coli, followed by Klebsiella pneumoniae. A complicated/severe infection state [odds ratio (OR), 15.27; p < 0.001] and a high level of C-reactive protein (OR, 1.012; p < 0.001) were independently associated with bacteremia. Corrected sodium (Na; OR, 1.062; p = 0.039), initial plasma glucose (OR, 1.003; p = 0.041), severe grade of DKA (OR, 13.41; p = 0.045), and the Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 1.08; p = 0.033) were identified as independent risk factors for the development of failure-stage AKI among septic patients with infection-precipitated DKA. Patients with failure-stage AKI had a higher frequency of incomplete recovery of renal function (20.4% of patients in failure vs. 5.9% of patients in risk and injury, p = 0.009). Bacteremia independently predicted the absence of complete recovery of renal function (OR, 5.86; p = 0.038). For patients with infection-precipitated DKA, the cli Continue reading >>

Overview Of The Management Of Acute Kidney Injury In Adults

Overview Of The Management Of Acute Kidney Injury In Adults

INTRODUCTION Acute kidney injury (AKI) is an abrupt and usually reversible decline in the glomerular filtration rate (GFR). This results in an elevation of serum blood urea nitrogen (BUN), creatinine, and other metabolic waste products that are normally excreted by the kidney. The term AKI, rather than acute renal failure (ARF), is increasingly used by the nephrology community to refer to the acute loss of kidney function. This term also highlights that injury to the kidney that does not result in "failure" is also of great clinical significance. In this topic review, the acute loss of kidney function will be referred to as AKI. The initial assessment of patients with AKI and management of the major complications of AKI are discussed here. The incidence, causes, diagnosis, and prevention of AKI are presented separately. (See "Diagnostic approach to adult patients with subacute kidney injury in an outpatient setting" and "Kidney and patient outcomes after acute kidney injury in adults" and "Possible prevention and therapy of ischemic acute tubular necrosis".) PATHOGENESIS AKI has multiple possible etiologies. Among hospitalized patients, AKI is most commonly due to either prerenal etiologies (volume depletion, "third spacing," effective volume depletion from heart failure or cirrhosis) or acute tubular necrosis (ATN) from ischemia, nephrotoxin exposure, or sepsis [1]. The pathogenesis of ATN is discussed elsewhere. (See "Pathogenesis and etiology of ischemic acute tubular necrosis" and "Pathogenesis, clinical features, and diagnosis of contrast-induced nephropathy".) Other frequent causes of AKI among either ambulatory or hospitalized patients include volume depletion, urinary obstruction, rapidly progressive glomerulonephritis, and acute interstitial nephritis. The path Continue reading >>

Incidence And Characteristics Of Acute Kidney Injury In Severe Diabetic Ketoacidosis

Incidence And Characteristics Of Acute Kidney Injury In Severe Diabetic Ketoacidosis

Go to: Introduction The incidence of diabetes mellitus is increasing worldwide affecting both types of the disease. The most frequent acute diabetic complications are hyperglycemic crises, namely diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state. Diabetic ketoacidosis results from an absolute insulin deficiency. Classical presentation associates a triad of uncontrolled hyperglycemia, metabolic acidosis and high ketone bodies concentration. Similarly to diabetes, the incidence of DKA increases over time [1], [2]. This may be a life-threatening condition due to severe clinical and biological impairments and treatment associated complications (cerebral edema, acute respiratory distress syndrome, hypokalaemia, hypophosphatemia). However, mortality is low and most of the time, death is related to the precipitating factor [3]–[6]. For this reason, admission of these patients in ICU is still debated. A grading system for severity of DKA was described previously [7]. Patients presenting the most severe grades or common severity criteria were considered for ICU admission. However this grading system is not recommended for clinical practice, resulting in wide variations in ICU utilisation for DKA, depending on the national practices, the number of DKA admitted in the units and the severity of the clinical status [8]. Interestingly, in the absence of randomised trials, there are no data showing any impact of the level of care on DKA mortality. To help clinicians, guidelines for DKA management are published and updated by the American Diabetic Association [6]. Their effect on clinical outcome is unclear as compliance to guidelines is poor in diabetes care and ICU [9], [10]. However, implementation of a local mandatory protocol seems more efficient to decrease ICU a Continue reading >>

Study: Kidney Injury Risk In Type 1 Children With Dka Is High

Study: Kidney Injury Risk In Type 1 Children With Dka Is High

A recent study found that in children with type 1 diabetes who were hospitalized for diabetic ketoacidosis (DKA), the risk of suffering an acute kidney injury is high. Based on these findings, researchers suggest in their study abstract that clinicians should be aware of these findings and “consider acute kidney injury as a frequent complication in this population.” In order to find out how many children hospitalized with DKA develop an acute kidney injury and to find out what the associated clinical and biochemical markers of an acute kidney injury are, researchers conducted a medical record review of 165 children with type 1 diabetes who were hospitalized with DKA between September 2008 and December 2013. The study took place at British Columbia Children’s Hospital in British Columbia, Canada. Researchers looked at records of children age 18 or younger with type 1 and DKA who had a complete medical record available for data analysis and defined an acute kidney injury using the serum creatinine criteria set by the Kidney Disease/Improving Global Outcomes (KDIGO). KDIGO, according to their website is a, “global organization developing and implementing evidence based clinical practice guidelines in kidney disease. It is an independent volunteer-led self-managed charity incorporated in Belgium accountable to the public and the patients it serves.” How Many Children Suffer Acute Kidney Injury from DKA? The study found that of the 165 children who were hospitalized with DKA, 106 or 64.2 percent developed an acute kidney injury. Acute kidney injury is measured in stages with stage 1 being the least severe. Of the 106 children who developed an acute kidney injury, 37 or 34.9 percent developed a stage 1 acute kidney injury, 48 or 45.3 percent developed a stage 2 acut Continue reading >>

Acute Kidney Injury In Children With Type 1 Diabetes Hospitalized For Diabetic Ketoacidosis

Acute Kidney Injury In Children With Type 1 Diabetes Hospitalized For Diabetic Ketoacidosis

Abstract: Importance Acute kidney injury (AKI) in children is associated with poor short-term and long-term health outcomes; however, the frequency of AKI in children hospitalized for diabetic ketoacidosis (DKA) has not been previously examined. Objectives To determine the proportion of children hospitalized for DKA who develop AKI and to identify the associated clinical and biochemical markers of AKI. Design, Setting, and Participants This medical record review of all DKA admissions from September 1, 2008, through December 31, 2013, was conducted at British Columbia Children’s Hospital, the tertiary pediatric hospital in British Columbia, Canada. Children aged 18 years or younger with type 1 diabetes and DKA and with complete medical records available for data analysis were included (n = 165). All data collection occurred between September 8, 2014, and June 26, 2015. Data analysis took place from August 25, 2015, to June 8, 2016. Main Outcomes and Measures Acute kidney injury was defined using Kidney Disease/Improving Global Outcomes serum creatinine criteria. Multinomial logistic regression was used to identify potential factors associated with AKI. Results Of the 165 children hospitalized for DKA, 106 (64.2%) developed AKI (AKI stage 1, 37 [34.9%]; AKI stage 2, 48 [45.3%]; and AKI stage 3, 21 [19.8%]). Two children required hemodialysis. In the adjusted multinomial logistic regression model, a serum bicarbonate level less than 10 mEq/L (compared with ≥10 mEq/L) was associated with a 5-fold increase in the odds of severe (stage 2 or 3) AKI (adjusted odds ratio [aOR], 5.22; 95% CI, 1.35-20.22). Each increase of 5 beats/min in initial heart rate was associated with a 22% increase in the odds of severe AKI (aOR, 1.22; 95% CI, 1.07-1.39). Initial corrected sodium leve Continue reading >>

Severe Acute Renal Failure In A Patient With Diabetic Ketoacidosis

Severe Acute Renal Failure In A Patient With Diabetic Ketoacidosis

1 King Khalid National Guard Hospital, Jeddah, Kingdom of Saudi Arabia, Department of Pediatrics, Division of Nephrology, Children's Hospital of Eastern Ontario, Ottawa, Canada, Canada 2 Department of Pediatrics, Division of Nephrology, Children's Hospital of Eastern Ontario, Ottawa, Canada Click here for correspondence address and email Acute renal failure (ARF) is a rare but potentially fatal complication of diabetic ketoacidosis (DKA). Early recognition and aggressive treatment of ARF during DKA may improve the prognosis of these patients. We present a case report of a 12 year old female admitted to the hospital with severe DKA as the 1s t manifestation of her diabetes mellitus. She presented with severe metabolic acidosis, hypophosphatemia, and oliguric ARF. In addition, rhabdomyolysis was noted during the course of DKA which probably contributed to the ARF. Management of DKA and renal replacement therapy resulted in quick recovery of renal function. We suggest that early initiation of renal replacement therapy for patients with DKA developing ARF may improve the potentially poor outcome of patients with ARF associated with DKA. How to cite this article: Al-Matrafi J, Vethamuthu J, Feber J. Severe acute renal failure in a patient with diabetic ketoacidosis. Saudi J Kidney Dis Transpl 2009;20:831-4 Diabetic ketoacidosis (DKA) occurs in 10 to 70% of children with type 1 diabetes mellitus (DM1) and has a significant risk of mortality, mostly due to cerebral edema. [1] Other potential complications of DKA include hypokalemia, hypophosphatemia, hypoglycemia, intracerebral and peripheral venous thrombosis, mucormycosis, rhabdomyolysis, acute pancreatitis, acute renal failure (ARF) and sepsis. The development of ARF with rhabdomyolysis is a rare but potentially lethal diso Continue reading >>

Severe Diabetic Ketoacidosis – A Remarkable Case Study

Severe Diabetic Ketoacidosis – A Remarkable Case Study

Summarized from Van de Vyver C, Damen J, Haentjens C et al. An exceptional case of diabetic ketoacidosis. Case Reports in Emergency Medicine 2017. Diabetic ketoacidosis (DKA) is a potentially life-threatening acute complication of type 1 diabetes caused by insulin deficiency. It is characterized by raised blood glucose (hyperglycemia), metabolic acidosis, and increased blood/urine ketones. Dehydration and electrolyte disturbance are common and affected patients may develop some degree of acute kidney injury (AKI) consequent on fluid loss (hypovolemia) due to osmotic diuresis associated with severe hyperglycemia. DKA evolves rapidly over a short time frame (hours rather than days) and can occur (rarely) in those with type 2 diabetes. This DKA case study is particularly noteworthy because of the severity of the hyperglycemia and acid-base disturbance, and the fact that the patient survived such profound metabolic disturbance and associated life-threatening hemodynamic changes. The case concerns a 33-year-old woman with ”brittle” type 1 diabetes treated with continuous subcutaneous insulin infusion (insulin pump). She had, in common with many brittle diabetics, a history of gastroparesis (delayed stomach emptying). Some 36 hours prior to emergency hospital admission she complained of abdominal pain and vomiting after attending a party. Her condition deteriorated before transfer to hospital. The ambulance team reported a rapid decline in Glasgow Coma Score (GCS) from 13 to 3 in only 10 minutes, sinus tachycardia, undetectable peripheral pulse, and hypotension (BP 99/52 mmHg). Clinical examination revealed severe dehydration and respiratory distress (respiration rate 40 breaths/min). Urgent intubation was necessary and systolic blood pressure dropped further to 55 mmHg. Continue reading >>

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