Sglt2 Inhibitors May Have An Increased Risk Of Acute Renal Failure (drug Safety Developments)
SGLT2 Inhibitors May Have an Increased Risk of Acute Renal Failure Written by: Heather Helmendach, Legal Assistant In previous articles, I have discussed SGLT2 inhibitor diabetes drugs such as Invokana, Farxiga, and Jardiance and the adverse events associated with them.Such side effects include diabetic ketoacidosis (DKA) and lower-limb amputations. A recent study identified a new possible side effect of these drugs through an analysis of the FDA Adverse Event Report System database (FAERS). The researchers found that SGLT2 inhibitors were associated with an increased risk of acute renal failure. According to the study, out of the 1,224 reported cases of acute renal failure that involved SGLT2 inhibitors, the drugs were defined as the "primary" or "secondary" causes of acute renal failure in 96.8% of the cases. Furthermore, the number ofacute renal failure reports for these drugs was significantly greater than those involving patients with Type 2 diabetes who were not treated with SGLT2 inhibitors. Researcher Amichai Perlman, PharmD provides her input on the study's findings: Our results should be interpreted with caution as this is an observational study with limited control of potential confounding factors...However, we believe that clinicians should consider simple measures to minimize this potential risk, including instructing patients to keep hydrated and avoid volume depletion; consider closer monitoring of kidney function in patients with concomitant ACE inhibitors and diuretics, especially in patients with impaired baseline renal function; and avoiding administration of SGLT2 inhibitors with nephrotoxic agents, such as NSAIDs, as well as to consider temporary withholding of SGLT2 inhibitors prior to radio-contrast studies. We are currently investigating possibl Continue reading >>
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 >>
Understanding Diabetic Ketoacidosis - Wsava2005 - Vin
World Small Animal Veterinary Association World Congress Proceedings, 2005 Assistant Professor of Small Animal Medicine Diabetic ketoacidosis (DKA) is a complication of unregulated diabetes mellitus (DM) that produces marked hyperglycemia, profound metabolic acidosis, and hyperketonemia in severely affected patients. DKA is often discussed as a condition that is separate from uncomplicated diabetes mellitus but, in fact, diabetes mellitus is a spectrum of disorders that ranges from non-ketotic hyperosmolar diabetes mellitus on one end to diabetic ketoacidosis on the other end. It is important to remember that most complicated diabetics have another medical problem. Thus, management of DKA must be performed in the context of any concurrent disorder. DKA can be precipitated by factors such as inadequate insulin therapy, physiologic stress, drugs that affect insulin production or action, bacterial infection, and decreased fluid intake. Concurrent illness is common in animals with DKA. In one study, about half of cats with DKA had azotemia on admission; azotemia was moderate to severe in 20% of those cats. Other concurrent disorders found in that same group of cats included: inflammatory bowel disease, asthma, pancreatitis, hyperthyroidism, urinary tract infection, neoplasm, and corticosteroid therapy. In dogs, concurrent disorders include: urinary tract infection, neoplasia, pneumonia, pyometra, prostatitis, renal failure, hyperadrenocorticism, heart failure, and drug therapy (corticosteroids or progestins), among others. Signalment: There is no characteristic or specific signalment for animals with DM or those likely to develop complicated DM. Gender. Middle-aged and older female dogs have an increased risk for the development of diabetes mellitus when compared to males. Continue reading >>
Acute Renal Failure In Diabetics
Acute renal failure in diabetic patients occurs, as a result of certain specific conditions. The most common of these are hyperglycaemic hyperosmolar coma, diabetic ketoacidosis, the use of radiocontrast media, and renal papillary necrosis. The management of diabetics with acute renal failure is essentially the same as for non-diabetic patients but may be complicated by the problems of metabolic control, vascular access, and vascular instability. Prevention is important as the development of acute renal failure adds considerably to the morbidity and mortality of these conditions and is often avoidable. This is a preview of subscription content, log in to check access. Unable to display preview. Download preview PDF. Keller V, Berger W, Ritz R, Truog P (1975) Course and prognosis of 86 episodes of diabetic coma: a five year experience with a uniform schedule of treatment. Diabetologia 11:93 Google Scholar Podolsky S (1978) Hyperosmolar non-ketotic coma in the elderly diabetic. Med Clin N Am 62:815 Google Scholar McCurdy DK (1970) Hyperosmolar hyperglycaemic nonketotic diabetic coma. Med Clin N Am 54:683 Google Scholar Gerich JE, Martin MM, Recant L (1971) Clinical and metabolic characteristics of hyperosmolar nonketotic coma. Diabetes 20:228 Google Scholar Khardori R, Soler NG (1984) Hyperosmolar hyperglycaemic nonketotic syndrome. Report of 22 cases and brief review. Am J Med 77:899 Google Scholar Nikolaides K, Barnett AH, Spiliopoulos AJ, Watkins PJ (1981) West Indian population of a large inner city diabetic clinic. Br Med J 283:1374 Google Scholar Arieff AI, Carroll HJ (1972) Nonketotic hyperosmolar coma with hyperglycaemia: clinical features, pathophysiology, renal function, acid base balance, plasma-cerebrospinal fluid equilibria, and the effects of therapy in 37 Continue reading >>
Diabetic Ketoacidosis
Figure 3. Timeline in DKA management. GCS:Glascow Coma Scale, CBC:Complete Blood Counting, ECG:Electrocardiogram, HR:Heart Rate, BP:Blood Pressure, BUN:Blood Urea Nitrogen, Cr: Creatinine, WBC:White Blood Cell, CRP:C-reactive protein, CE:Cerebral edema (adapted from reference 165) Figure 4. A 15 years old male patient firstly diagnosed T1DM with DKA infected by rhino-orbita-cerebral mucormycozis (Picture from the reference [218]) 1. Introduction A chronic autoimmune destruction of the pancreatic beta cells results in decreasing endogenous insulin secretion and the clinical manifestation of type 1 diabetes mellitus (T1DM). The clinical onset of the disease is often acute in children and adolescents and diabetic ketoacidosis (DKA) is present in 20-74% of the patients [1-7]. DKA is a serious condition that requiring immediate intervention. Even with appropriate intervention, DKA is associated with significant morbidity and possible mortality in diabetic patients in the pediatric age group [8]. Young age and female sex have been associated with an increased frequency of DKA [3,9]. The triad of uncontrolled hyperglycemia, metabolic acidosis and increased total body ketone concentration characterizes DKA [10]. In addition to possible acute complications, it may also influence the later outcome of diabetes [11]. 2. Epidemiology Worldwide, an estimated 65 000 children under 15 years old develop T1DM each year, and the global incidence in children continues to increase at a rate of 3% a year [12,13]. The current incidence in the UK is around 26/100 000 per year [14]. Patterson et al. were aimed to establish 15-year incidence trends for childhood T1DM in European centres with EURODIAB study. 29 311 new cases of T1DM were diagnosed in children before their 15th birthday during a 1 Continue reading >>
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.
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 >>
Hyperglycemic Crises In Diabetes
Ketoacidosis and hyperosmolar hyperglycemia are the two most serious acute metabolic complications of diabetes, even if managed properly. These disorders can occur in both type 1 and type 2 diabetes. The mortality rate in patients with diabetic ketoacidosis (DKA) is <5% in experienced centers, whereas the mortality rate of patients with hyperosmolar hyperglycemic state (HHS) still remains high at ∼15%. The prognosis of both conditions is substantially worsened at the extremes of age and in the presence of coma and hypotension (1–10). This position statement will outline precipitating factors and recommendations for the diagnosis, treatment, and prevention of DKA and HHS. It is based on a previous technical review (11), which should be consulted for further information. PATHOGENESIS Although the pathogenesis of DKA is better understood than that of HHS, the basic underlying mechanism for both disorders is a reduction in the net effective action of circulating insulin coupled with a concomitant elevation of counterregulatory hormones, such as glucagon, catecholamines, cortisol, and growth hormone. These hormonal alterations in DKA and HHS lead to increased hepatic and renal glucose production and impaired glucose utilization in peripheral tissues, which result in hyperglycemia and parallel changes in osmolality of the extracellular space (12,13). The combination of insulin deficiency and increased counterregulatory hormones in DKA also leads to the release of free fatty acids into the circulation from adipose tissue (lipolysis) and to unrestrained hepatic fatty acid oxidation to ketone bodies (β-hydroxybutyrate [β-OHB] and acetoacetate), with resulting ketonemia and metabolic acidosis. On the other hand, HHS may be caused by plasma insulin concentrations that are in Continue reading >>
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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 >>
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 >>
Severe Acute Renal Failure Requiring Dialysis In Children With Diabetic Ketoacidosis
Endocrine Abstracts (2016) 45 P15 | DOI: 10.1530/endoabs.45.P15 Severe acute renal failure requiring dialysis in children with diabetic ketoacidosis Evagelia Paraskevopoulou1, Amanda Peacock2, Leena Patel3, Christine Burren3, James Yong2, Murray Bain1 & Christina Wei1 1St Georges Hospital, London, UK; 2Leeds Childrens Hospital, Leeds, UK; 3Bristol Royal Hospital for Children, Bristol, UK. Introduction: Acute renal failure (ARF) is a rare but life-threatening complication of severe diabetic ketoacidosis (DKA) in children. Aim: To characterise the presentation, treatment and clinical course of children with DKA complicated by severe ARF requiring renal support. Method: Retrospective notes review of patients aged <16 years admitted in 20112016 to 3 UK regional paediatric intensive care units (St Georges Hospital, London, Leeds Childrens Hospital and Bristol Royal Hospital for Children) with DKA complicated by ARF requiring renal dialysis. Results: [Median (range)]. Five (male=2, female=3) cases with type 1 diabetes aged 13.5(9.615.9) years were identified, including 4 newly diagnosed and 1 known patient with poor compliance. All presented in winter between December and April. Length of PICU stay was 8(220) days. Four were ventilated for 3.5(311) days, and 3 required inotropic support. At presentation, HbA1C was 148(90173) mmol/mol and glucose 35(2847) mmol/l. Blood gas analysis showed an initial pH of <6.8 in all patients, base excess between unrecordable and 28, bicarbonate between unrecordable and 4.6 mmol/l; and took 2(23) days to normalise. Level of dehydration was estimated at 8(710)%. All required additional fluid boluses on clinical judgement and, received intravenous fluids and insulin 0.050.1 U/kg according to national DKA protocol. Intravenous antibiotics were g Continue reading >>
Pediatric Diabetic Ketoacidosis
Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD more... Diabetic ketoacidosis, in pediatric and adult cases, is a metabolic derangement caused by the absolute or relative deficiency of the anabolic hormone insulin. Together with the major complication of cerebral edema, it is the most important cause of mortality and severe morbidity in children with diabetes. Symptoms of acidosis and dehydration include the following: Abdominal pain - May be severe enough to present as a surgical emergency Shortness of breath - May be mistaken for primary respiratory distress Confusion and coma in the absence of recognized head injury [ 1 ] Symptoms of hyperglycemia, a consequence of insulin deficiency, include the following: Polyuria - Increased volume and frequency of urination Nocturia and secondary enuresis in a previously continent child Weight loss - May be dramatic due to breakdown of protein and fat stores Patients with diabetic ketoacidosis may also have the following signs and symptoms: Signs of intercurrent infection (eg, urinary or respiratory tract infection) Weakness and nonspecific malaise that may precede other symptoms of hyperglycemia Kussmaul breathing or deep sighing respiration - A mark of acidosis Ketone odor - Patient may have a smell of ketones on his/her breath Impaired consciousness - Occurs in approximately 20% of patients Abdominal tenderness - Usually nonspecific or epigastric in location Most cases of cerebral edema occur 4-12 hours after initiation of treatment. Diagnostic criteria of cerebral edema include the following: Abnormal motor or verbal response to pain Cranial nerve palsy - Especially III, IV, and VI Abnormal neurogenic breathing pattern (eg, Cheyne-Stokes), apneusis Altered mentation, fluctuating Continue reading >>
Extreme Insulin Resistance In A Patient With Diabetes Ketoacidosis And Acute Myocardial Infarction
Case Reports in Endocrinology Volume 2013 (2013), Article ID 520904, 7 pages 1Division of Endocrinology, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA 2Division of Endocrinology, Maimonides Medical Center, Brooklyn, NY 11219, USA Academic Editors: O. Isozaki, W. V. Moore, and R. Murray Copyright © 2013 Yin H. Oo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Hyperglycemia is common in hospitalized patients and associated with adverse clinical outcomes. In hospitalized patients, multiple factors contribute to hyperglycemia, such as underlying medical conditions, pathophysiological stress, and medications. The development of transient insulin resistance is a known cause of hyperglycemia in both diabetic and nondiabetic patients. Though physicians are familiar with common diseases that are known to be associated with insulin resistance, the majority of us rarely come across a case of extreme insulin resistance. Here, we report a case of prolonged course of extreme insulin resistance in a patient admitted with diabetic ketoacidosis (DKA) and acute myocardial infarction (MI). The main purpose of this paper is to review the literature to identify the underlying mechanisms of extreme insulin resistance in a patient with DKA and MI. We will also briefly discuss the different clinical conditions that are associated with insulin resistance and a general approach to a patient with severe insulin resistance. 1. Introduction In hospitalized patients, the development of transient insulin resistance related to different medical conditions such as acute myocardial infarction (MI), sepsis, and Continue reading >>
Prime Pubmed | Severe Acute Renal Failure In A Patient With Diabetic Ketoacidosi
Type your tag names separated by a space and hit enter Severe acute renal failure in a patient with diabetic ketoacidosis. 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. Al-Matrafi J, Vethamuthu J, Feber J: "Severe acute renal failure in a patient with diabetic ketoacidosis." Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia, vol. 20, no. 5, 2009, pp. 831-4, Accessed December 3, 2018. Al-Matrafi J, Vethamuthu J, Feber J. Severe acute renal failure in a patient with diabetic ketoacidosis. Saudi J Kidney Dis Transpl 2009;20(5):831-4 Accessed December 3, 2018. Al-Matrafi J & Vethamuthu J & Feber J. (2009). Severe acute renal failure in a patient with diabetic ketoacidosis. Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia, 20, pp. 831-4. Al-Matrafi J, Vethamuthu J, Feber J. Severe acute renal failure in a patient with diabetic ketoacidosis. Saudi Continue reading >>
Diabetic Ketoacidosis In Patients With Chf And/or Renal Failure
Diabetic Ketoacidosis in Patients With CHF and/or Renal Failure How do you manage diabetic ketoacidosis (DKA) in patients with congestive heart failure (CHF) and/or renal failure? Response from Zachary T. Bloomgarden, MD Mortality from DKA persists at 3% to 4% and is primarily due to either presentation late in the course of the syndrome, concurrent cardiac illness, or infection.[ 1 ] Crucial aspects of DKA management involve adequate replacement of fluids and electrolytes, particularly potassium, and the continuous administration of insulin. As DKA typically leads to profound dehydration, it tends not to be associated with overt CHF. If individuals with impaired cardiac function develop DKA, hemodynamic assessments must be made in an intensive care setting in order to administer adequate quantities of fluid while avoiding overhydration. Of interest, it has been reported that DKA is sometimes associated with respiratory distress syndrome, so that under these circumstances clinical assessment alone can be misleading and the finding of rales with respiratory symptoms may be due to capillary-alveolar leak rather than to CHF per se.[ 2 ] It should be noted that the administration of sodium bicarbonate for acidosis is especially detrimental in these patients in view of the accompanying sodium burden. As such, treatment with sodium bicarbonate appears to paradoxically increase acetoacetate and beta-hydroxybutyrate[ 3 ] and in general it should be avoided in DKA management. Renal failure occurs with increased frequency in patients with diabetes. Fortunately, the coincidence of type 1 diabetes with DKA and acute renal failure is uncommon.[ 4 ] The management of DKA in this setting clearly requires intensive monitoring, as volume overload and hyperkalemia may complicate the con Continue reading >>
