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Can Dka Cause Renal Failure?

Diabetic Ketoacidosis Producing Extreme Hyperkalemia In A Patient With Type 1 Diabetes On Hemodialysis

Diabetic Ketoacidosis Producing Extreme Hyperkalemia In A Patient With Type 1 Diabetes On Hemodialysis

Hodaka Yamada1, Shunsuke Funazaki1, Masafumi Kakei1, Kazuo Hara1 and San-e Ishikawa2[1] Division of Endocrinology and Metabolism, Jichi Medical University Saitama Medical Center, Saitama, Japan [2] Division of Endocrinology and Metabolism, International University of Health and Welfare Hospital, Nasushiobara, Japan Summary 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. Patients with type 1 diabetes on hemodialysis may develop ketoacidosis because of discontinuation of insulin treatment. Patients on hemodialysis who develop ketoacidosis may have hyperkalemia because of anuria. Absolute insulin deficit alters potassium distribution between the intracellular and extracellular space, and anuria abolishes urinary excretion of potassium. Rapid hemodialysis along with intensive insulin therapy can improve hyperkalemia, while fluid infusions may worsen heart failure in patients with ketoacidosis who routinely require hemodialysis. Background Diabetic ketoacidosis (DKA) is a very common endocrinology emergency. It is usually associated with severe circulatory Continue reading >>

Diabetes - Type 1

Diabetes - Type 1

Description An in-depth report on the causes, diagnosis, and treatment of type 1 diabetes. Alternative Names Type 1 diabetes; Insulin-dependent diabetes; Juvenile diabetes Highlights Type 1 Diabetes In type 1 diabetes, the pancreas does not produce insulin. Insulin is a hormone that is involved in regulating how the body converts sugar (glucose) into energy. People with type 1 diabetes need to take daily insulin shots and carefully monitor their blood glucose levels. Type 1 diabetes is much less common than type 2 diabetes. It accounts for 5 - 10% of all diabetes cases. Type 1 diabetes can occur at any age, but it usually first develops in childhood or adolescence. Symptoms of Diabetes Symptoms of both type 1 and type 2 diabetes include: Frequent urination Excessive thirst Extreme hunger Sudden weight loss Extreme fatigue Irritability Blurred vision In general, the symptoms of type 1 diabetes come on more abruptly and are more severe than those of type 2 diabetes. Warning Signs of Hypoglycemia Hypoglycemia (low blood sugar) occurs when blood sugar (glucose) levels fall below normal. All patients with diabetes should be aware of these symptoms of hypoglycemia: Sweating Trembling Hunger Rapid heartbeat Confusion It is important to quickly treat hypoglycemia and raise blood sugar levels by eating sugar, sucking on hard candy, or drinking fruit juice. Patients who are at risk for hypoglycemia should carry some sugar product, or an emergency glucagon injection kit, in case an attack occurs. In rare and worst cases, hypoglycemia can lead to coma and death. Regular blood sugar monitoring throughout the day can help you avoid hypoglycemia. Patients are also encouraged to wear a medical alert ID bracelet or necklace that states they have diabetes and that they take insulin. Pati Continue reading >>

Management Of A Dka Patient With Severe Metabolic And Ketoacidosis With Chronic Renal Insufficiency Brian Albany Otterbein University, Boomer.albany@otterbein.edu

Management Of A Dka Patient With Severe Metabolic And Ketoacidosis With Chronic Renal Insufficiency Brian Albany Otterbein University, [email protected]

Otterbein University Digital Commons @ Otterbein MSN Student Scholarship Student Research & Creative Work Fall 2014 Follow this and additional works at: Part of the Endocrine System Diseases Commons, Medical Pathology Commons, and the Nursing Commons This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has been accepted for inclusion in MSN Student Scholarship by an authorized administrator of Digital Commons @ Otterbein. For more information, please contact [email protected] Recommended Citation Albany, Brian, "Management of a DKA patient with severe metabolic and ketoacidosis with chronic renal insufficiency" (2014). MSN Student Scholarship. Paper 6. Implications for nursing care Management of a DKA patient with severe metabolic and ketoacidosis with chronic renal insufficiency Brian Albany BSN, CCRN Introduction Case Study References Underlying Pathophysiology Diabetic ketoacidosis (DKA) serves as one the leading causes of mortality in diabetic patients [14]. The mortality has decreased over the past several decades due to the rapid recognition of the disease state and the improvement of management of DKA [14]. Despite a decline in mortality rates over the past twenty years from 7.96% to 0.67%, errors in management of the disease state are associated with significant morbidity and mortality [2]. Utilization of DKA protocols in the acute care setting have allowed congruency in care and delivery of effective lifesaving treatment. Despite advances in standardized DKA protocols, there still remains a gap in how to manage specific patient populations with end stage renal disease. Understanding the pathophysiology behind these patient populations will yield better outcomes with the ultimate Continue reading >>

Medications And Kidney Complications, Symptoms Of Diabetic Ketoacidosis

Medications And Kidney Complications, Symptoms Of Diabetic Ketoacidosis

Your kidneys are two organs located on either side of your backbone just above your waist. They remove waste and excess fluid from the blood, maintain the balance of salt and minerals in the blood, and help regulate blood pressure, among other functions. 1 If damaged, they can cause you to have health issues. Acute Renal Injury A sudden loss of kidney function can be caused by: lack of blood flow to the kidneys, direct damage to the kidneys, or blockage of urine from the kidneys. Common causes of these losses of function may include: traumatic injury, dehydration, severe systemic infection (sepsis), damage from drugs/toxins or pregnancy complications. 2 Chronic Kidney Disease When kidney damage and decreased function lasts longer than three months, it is called chronic kidney disease (CKD). CKD can be dangerous, as you may not have any symptoms until after the kidney damage, which may or may not be able to be repaired, has occurred. High blood pressure and diabetes (types 1 and 2) are the most common causes of CKD. 3 Causes of Chronic Kidney Disease There are also other causes of CKD. These can include: Immune system conditions (e.g., lupus) Long-term viral illnesses (HIV/AIDS, hepatitis B, hepatitis C) Pyelonephritis (urinary tract infections within the kidneys) Inflammation in the kidney’s filters (glomeruli) Polycystic kidney disease (fluid-filled cysts form in the kidneys) Congenital defects (malformations present at birth) Toxins, chemicals Type 2 Diabetes Symptoms People with uncontrolled type 2 diabetes have high levels of sugar (glucose) building up and circulating in the blood. This high blood sugar can cause heart disease, stroke, kidney disease, blindness and nerve damage, among other complications. 5 You may have no type 2 diabetes symptoms, or symptoms ma Continue reading >>

Diabetic Ketoacidosis In Dogs

Diabetic Ketoacidosis In Dogs

My dog is diabetic. He has been doing pretty well overall, but recently he became really ill. He stopped eating well, started drinking lots of water, and got really weak. His veterinarian said that he had a condition called “ketoacidosis,” and he had to spend several days in the hospital. I’m not sure I understand this disorder. Diabetic ketoacidosis is a medical emergency that occurs when there is not enough insulin in the body to control blood sugar (glucose) levels. The body can’t use glucose properly without insulin, so blood glucose levels get very high, and the body creates ketone bodies as an emergency fuel source. When these are broken down, it creates byproducts that cause the body’s acid/base balance to shift, and the body becomes more acidic (acidosis), and it can’t maintain appropriate fluid balance. The electrolyte (mineral) balance becomes disrupted which can lead to abnormal heart rhythms and abnormal muscle function. If left untreated, diabetic ketoacidosis is fatal. How could this disorder have happened? If a diabetic dog undergoes a stress event of some kind, the body secretes stress hormones that interfere with appropriate insulin activity. Examples of stress events that can lead to diabetic ketoacidosis include infection, inflammation, and heart disease. What are the signs of diabetic ketoacidosis? The signs of diabetic ketoacidosis include: Excessive thirst/drinking Increased urination Lethargy Weakness Vomiting Increased respiratory rate Decreased appetite Weight loss (unplanned) with muscle wasting Dehydration Unkempt haircoat These same clinical signs can occur with other medical conditions, so it is important for your veterinarian to perform appropriate diagnostic tests to determine if diabetic ketoacidosis in truly the issue at hand Continue reading >>

Distinctive Characteristics And Specific Management Of Diabetic Ketoacidosis In Patients With Acute Myocardial Infarction, Stroke And Renal Failure

Distinctive Characteristics And Specific Management Of Diabetic Ketoacidosis In Patients With Acute Myocardial Infarction, Stroke And Renal Failure

1. Introduction Diabetic ketoacidosis (DKA) is considered a predominantly acute type 1 diabetic complication, although it may occur in type 2 diabetes as well, particularly in patients who already have a decreased insulin secretion capacity. Stress –induced burst in catecholamine and ACTH secretion in acute myocardial infarction (AMI) promotes release of free fatty acids and their hepatic and muscular tissue utilization. The impairment in insulin-mediated intracellular glucose influx owing to the absent or insufficient pancreatic insulin secretion is the prerequisite for the occurrence of diabetic ketoacidosis. The results of the analysis of acid – base disturbances from our previous study [26] performed in the intensive-care unit in diabetics and non-diabetics suffering acute myocardial infarction are shown in Fig. 1. Cardiovascular accidents have a marked place among the possible causes of diabetic ketoacidosis. Cardiovascular morbidity influences the severity and duration of diabetic ketoacidosis and limits the first and most important step in its treatment- the fluid resuscitation. The resulting hyperosmolarity of body fluids precipitates a pro-thrombotic state, thus aggravating prognosis in patients with myocardial infarction. The clinical features of hyperglycemic/hyperosmolar state and diabetic ketoacidosis may overlap and are observed simultaneously (overlap cases) [44]. Acid-base disturbances in diabetics and non-diabetics suffering acute myocardial infarction: Almost one-third of diabetic patients with acute myocardial infarction had un-compensated metabolic acidosis defined as pH< 35, HCO3- < 22mmol/L. Although acidosis was mild in most of the cases at least third of these patients had criteria for true diabetic ketoacidosis (pH<30, HCO3- <15mmol/L). Addi Continue reading >>

Severe Acute Renal Failure In A Patient With Diabetic Ketoacidosis.

Severe Acute Renal Failure In A Patient With Diabetic Ketoacidosis.

Abstract 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 im-prove 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. Continue reading >>

Feline Chronic Kidney Disease

Feline Chronic Kidney Disease

ON THIS PAGE: Risk Factors Home > Related Diseases > Diabetes It is not uncommon for a CKD cat to also have or develop diabetes. The dietary needs of a diabetic cat may seem incompatible with the needs of a CKD cat but the diabetes must take precedence. What is Diabetes Mellitus? Insulin is a hormone which enables the body to process food and to produce energy from it. Diabetes mellitus is a disease in which: not enough insulin is produced by the pancreas; or the cat’s body cells do not properly process insulin which the pancreas has produced. As a result, the cat develops high blood sugar levels (hyperglycaemia), which eventually lead to high sugar levels in the urine (glucosuria). Diabetes may present as: uncomplicated; or diabetes with ketoacidosis (DKA) Cats with the former may only have mild symptoms, at least in the early stages, but cats with ketoacidosis are usually very ill, and may die if not treated promptly. There is another, much rarer form of diabetes called diabetes insipidus which is beyond the scope of this website. Cornell University College of Veterinary Medicine has a good general overview of diabetes in cats. Feline diabetes mellitus: from diagnosis to therapy (2009) is a helpful article by Dr DL Zoran. Feline Diabetes provides detailed answers to frequently asked questions. Risk Factors Increasing age is a factor (as it is for CKD cats). Steroid-induced diabetes in cats (2013) Peterson ME Veterinary Endocrinology says "The average age at diagnosis for feline diabetes is 10 years, with a peak incidence between 9 and 13 years." Obesity in cats, as in humans, is a strong predisposing factor for diabetes. For some reason, male cats and neutered cats are more at risk of diabetes. Burmese cats in the UK and Australasia (but not the USA) appear to be mo Continue reading >>

Diabetic Ketoacidosis Causes, Symptoms, Treatment, And Complications

Diabetic Ketoacidosis Causes, Symptoms, Treatment, And Complications

Diabetic ketoacidosis definition and facts Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes (though rare, it can occur in people with type 2 diabetes) that occurs when the body produces high levels of ketones due to lack of insulin. Diabetic ketoacidosis occurs when the body cannot produce enough insulin. The signs and symptoms of diabetic ketoacidosis include Risk factors for diabetic ketoacidosis are type 1 diabetes, and missing insulin doses frequently, or being exposed to a stressor requiring higher insulin doses (infection, etc). Diabetic ketoacidosis is diagnosed by an elevated blood sugar (glucose) level, elevated blood ketones and acidity of the blood (acidosis). The treatment for diabetic ketoacidosis is insulin, fluids and electrolyte therapy. Diabetic ketoacidosis can be prevented by taking insulin as prescribed and monitoring glucose and ketone levels. The prognosis for a person with diabetic ketoacidosis depends on the severity of the disease and the other underlying medical conditions. Diabetic ketoacidosis (DKA) is a severe and life-threatening complication of diabetes. Diabetic ketoacidosis occurs when the cells in our body do not receive the sugar (glucose) they need for energy. This happens while there is plenty of glucose in the bloodstream, but not enough insulin to help convert glucose for use in the cells. The body recognizes this and starts breaking down muscle and fat for energy. This breakdown produces ketones (also called fatty acids), which cause an imbalance in our electrolyte system leading to the ketoacidosis (a metabolic acidosis). The sugar that cannot be used because of the lack of insulin stays in the bloodstream (rather than going into the cell and provide energy). The kidneys filter some of the glucose (suga Continue reading >>

Case Report €¢ Observations De Cas

Case Report €¢ Observations De Cas

Diabetic ketoacidosis in the dialysis-dependent patient: two case reports and recommendations for treatment Jamie Blicker, MD; Anthony M. Herd, MD; Joanne Talbot, MD Introduction Diabetic ketoacidosis (DKA) is a complex medical disor- der characterized by abnormalities in electrolyte, acid-base and volume status. DKA management is particularly chal- lenging in patients with chronic renal failure on hemodial- ysis. Although the management of DKA is well-estab- lished,1,2 there is a paucity of literature describing DKA management in patients with concomitant renal failure re- quiring hemodialysis. A Medline search using a variety of search terms including “DKA AND renal failure,†“DKA AND chronic renal failure,†“DKA AND dialysis†and “DKA AND hemodialysis†returned only 2 relevant cita- tions.3,4 This article describes 2 dialysis-dependent patients who presented to the emergency department (ED) with DKA, 1 patient with volume overload and 1 with dehydration. Pre- sentation of these 2 case reports is followed by a discus- sion of key therapeutic issues. Case 1 A 32-year-old woman with insulin dependent diabetes mellitus and chronic renal failure on thrice-weekly he- modialysis presented to our ED with nausea, vomiting and abdominal pain. She had taken no insulin for 24 hours be- cause of anorexia. On presentation she had marked ketotic halitosis with Kussmaul’s respirations. Her vital signs in- cluded a temperature of 36.0°C, heart rate of 94 beats/min, respiratory rate of 20 breaths/min, blood pressure of 178/108 mm Hg, and oxygen saturation of 93%. Clinical examination was unremarkable apart from bilateral lung crackles, an S4 gallop and distended jugular veins. Her hematocrit was 0.255 g/L, and total white blood cell co Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetes mellitus is the name given to a group of conditions whose common hallmark is a raised blood glucose concentration (hyperglycemia) due to an absolute or relative deficiency of the pancreatic hormone insulin. In the UK there are 1.4 million registered diabetic patients, approximately 3 % of the population. In addition, an estimated 1 million remain undiagnosed. It is a growing health problem: In 1998, the World Health Organization (WHO) predicted a doubling of the worldwide prevalence of diabetes from 150 million to 300 million by 2025. For a very tiny minority, diabetes is a secondary feature of primary endocrine disease such as acromegaly (growth hormone excess) or Cushing’s syndrome (excess corticosteroid), and for these patients successful treatment of the primary disease cures diabetes. Most diabetic patients, however, are classified as suffering either type 1 or type 2 diabetes. Type 1 diabetes Type 1 diabetes, which accounts for around 15 % of the total diabetic population, is an autoimmune disease of the pancreas in which the insulin-producing β-cells of the pancreas are selectively destroyed, resulting in an absolute insulin deficiency. The condition arises in genetically susceptible individuals exposed to undefined environmental insult(s) (possibly viral infection) early in life. It usually becomes clinically evident and therefore diagnosed during late childhood, with peak incidence between 11 and 13 years of age, although the autoimmune-mediated β-cell destruction begins many years earlier. There is currently no cure and type 1 diabetics have an absolute life-long requirement for daily insulin injections to survive. Type 2 diabetes This is the most common form of diabetes: around 85 % of the diabetic population has type 2 diabetes. The primary prob Continue reading >>

Invokana Ketoacidosis, Kidney Failure, Kidney Disease, Heart Attack, Stroke, Amputation Lawsuits

Invokana Ketoacidosis, Kidney Failure, Kidney Disease, Heart Attack, Stroke, Amputation Lawsuits

If you or someone you love have suffered side effects such as Diabetic Ketoacidosis, Kidney Disease, Acute/Kidney Failure, Heart Attack, Stroke or Amputation after starting Invokana, Invokamet, Farxiga, Jardiance, Xigduo XR or Glyxambi, you may be eligible for compensation through a defective drug lawsuit against the manufacturer. Our Invokana attorneys are standing by, waiting to assist. Lawsuits allege that Janssen / Johnson & Johnson, manufacturer of Invokana, a popular type two diabetes drug, failed to warn both the medical community and consumers of serious potential side effects including heart attacks, stroke, amputation, kidney failure, kidney disease and diabetic ketoacidosis. Ketoacidosis is a serious condition, usually requiring hospitalization due to the possibility of fatal brain swelling, coma, and severe dehydration. It’s also been alleged that had the public been properly warned, doctors and patients may have chosen something other than Invokana for diabetes management or at the very least, monitored for health issues more frequently. New Lawsuit Accuses Johnson & Johnson, Janssen Pharmaceuticals of Failure to Adequately Research Invokana and Failure to Warn of Health Risks July 13, 2017 – In a lawsuit filed July 3, 2017, plaintiff Martha Williams of Tennessee accuses Janssen Pharmaceuticals and parent company Johnson & Johnson of failure to adequately research all potential health risks of its new generation diabetes drug Invokana as well as failure to warn the public and medical community of such risks. The lawsuit blames an onset of acute renal failure, a urinary tract infection, dehydration and hypokalemia suffered by Williams just one month after starting the medication. “Consumers of Invokana and their physicians relied on the Defendants’ f Continue reading >>

Understanding And Treating Diabetic Ketoacidosis

Understanding And Treating Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a serious metabolic disorder that can occur in animals with diabetes mellitus (DM).1,2 Veterinary technicians play an integral role in managing and treating patients with this life-threatening condition. In addition to recognizing the clinical signs of this disorder and evaluating the patient's response to therapy, technicians should understand how this disorder occurs. DM is caused by a relative or absolute lack of insulin production by the pancreatic b-cells or by inactivity or loss of insulin receptors, which are usually found on membranes of skeletal muscle, fat, and liver cells.1,3 In dogs and cats, DM is classified as either insulin-dependent (the body is unable to produce sufficient insulin) or non-insulin-dependent (the body produces insulin, but the tissues in the body are resistant to the insulin).4 Most dogs and cats that develop DKA have an insulin deficiency. Insulin has many functions, including the enhancement of glucose uptake by the cells for energy.1 Without insulin, the cells cannot access glucose, thereby causing them to undergo starvation.2 The unused glucose remains in the circulation, resulting in hyperglycemia. To provide cells with an alternative energy source, the body breaks down adipocytes, releasing free fatty acids (FFAs) into the bloodstream. The liver subsequently converts FFAs to triglycerides and ketone bodies. These ketone bodies (i.e., acetone, acetoacetic acid, b-hydroxybutyric acid) can be used as energy by the tissues when there is a lack of glucose or nutritional intake.1,2 The breakdown of fat, combined with the body's inability to use glucose, causes many pets with diabetes to present with weight loss, despite having a ravenous appetite. If diabetes is undiagnosed or uncontrolled, a series of metab Continue reading >>

Diabetic Ketoacidosis Associated With Acute Kidney Injury

Diabetic Ketoacidosis Associated With Acute Kidney Injury

A new Journal of American Medical Association article has shown that there is a high rate of occurrence of acute kidney injury (AKI) in children hospitalized with a diagnosis diabetic ketoacidosis (DKA). Acute kidney injury is one of the most common causes of renal injury that can arise from several aetiologies. Based on predisposing factors, the causes may be categorized into 3 classes: pre-renal, renal or post-renal. In cases of volume depletion, like that which occurs in diabetic ketoacidosis (a complication of diabetes where there is high ketone production), perfusion to kidneys is impaired and that is when the kidneys start to lose their functioning. Since acute kidney injury in children is associated with a poor short term and long term outcome, in a new JAMA article, and for the first time, researchers have evaluated the rate of acute kidney injury (AKI) in pediatric patients who were hospitalized for the diabetic ketoacidosis. This study was conducted at the British Columbia Children’s Hospital from 2008 through 2013. 165 children aged 18 years or younger with type 1 diabetes, DKA and with complete medical records available for data analysis were included. The primary outcome was the development of acute kidney injury defined using Kidney Disease/Improving Global Outcomes serum creatinine criteria. As per findings, in the designed timeframe, of the 165 children hospitalized for DKA, 106 (64.2%) developed AKI.Two children required hemodialysis. Statistical analysis has shown that a serum bicarbonate level of less than 10 mEq/L was associated with a 5-fold increased risk of developing severe kidney injury. This means that the incidence of acute kidney injury is directly associated with the severity of the acidosis resulting from DKA. Increase in heart rate (demo Continue reading >>

Acute Kidney Injury As A Severe Complication Of Diabetic Ketoacidosis In Children: A Case Report

Acute Kidney Injury As A Severe Complication Of Diabetic Ketoacidosis In Children: A Case Report

Background Diabetic Ketoacidoasis (DKA) is associated with significant morbidity and mortality and probably could be prevented by earlier diagnosis of diabetes mellitus (DM) and intervention. The level alertness of primary care doctors and knowledge on DM play a role to prevent severe complication of DKA. Methods We reported a diabetic ketoacidosis patient developing acute kidney injury at Hasan Sadikin General Hospital Bandung, Indonesia. Results A 12-year-old girl from a rural area was admitted to our pediatric emergency with decreased consciousness. We reviewed there was a history of polyuria, polydipsia and marked weight loss. When she arrived at hospital, she was very ill, comatose state, severe dehydration and typical Kussmaul breathing. Her heart rate was 140/min with thread pulse, low blood pressure, dry mucous membranes, sunken eyes, poor capillary return, and cold fingers. Laboratory analysis showed her blood glucose level was 890 mg/dl, severe metabolic acidosis and urine ketones 3+. The patient was resuscitated with iv fluid as soon as possible, followed by insulin and potassium chloride. On day 2 she developed oliguric and her serum creatinin and urea levels were 2.25 and 124 mg/dl that impressed as acute kidney injury. After fluid restriction she had persistent oliguric, increased serum creatinin and urea up to 7.34 and 234 mg/dl warranted initiation of peritoneal dialysis. After peritoneal dialysis and DKA management she showed a good improvement. Continue reading >>

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