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 >>
Diabetic Ketoacidosis
Professor of Pediatric Endocrinology University of Khartoum, Sudan Introduction DKA is a serious acute complications of Diabetes Mellitus. It carries significant risk of death and/or morbidity especially with delayed treatment. The prognosis of DKA is worse in the extremes of age, with a mortality rates of 5-10%. With the new advances of therapy, DKA mortality decreases to > 2%. Before discovery and use of Insulin (1922) the mortality was 100%. Epidemiology DKA is reported in 2-5% of known type 1 diabetic patients in industrialized countries, while it occurs in 35-40% of such patients in Africa. DKA at the time of first diagnosis of diabetes mellitus is reported in only 2-3% in western Europe, but is seen in 95% of diabetic children in Sudan. Similar results were reported from other African countries . Consequences The latter observation is annoying because it implies the following: The late diagnosis of type 1 diabetes in many developing countries particularly in Africa. The late presentation of DKA, which is associated with risk of morbidity & mortality Death of young children with DKA undiagnosed or wrongly diagnosed as malaria or meningitis. Pathophysiology Secondary to insulin deficiency, and the action of counter-regulatory hormones, blood glucose increases leading to hyperglycemia and glucosuria. Glucosuria causes an osmotic diuresis, leading to water & Na loss. In the absence of insulin activity the body fails to utilize glucose as fuel and uses fats instead. This leads to ketosis. Pathophysiology/2 The excess of ketone bodies will cause metabolic acidosis, the later is also aggravated by Lactic acidosis caused by dehydration & poor tissue perfusion. Vomiting due to an ileus, plus increased insensible water losses due to tachypnea will worsen the state of dehydr Continue reading >>
Diabetic Nephropathy - Kidney Disease
Tweet Kidney disease amongst diabetics is commonly called diabetic nephropathy. Statistically, around 40% of people with diabetes develop nephropathy but it is possible to prevent or delay through control of both blood glucose and blood pressure levels. Diabetes affects the arteries of the body and as the kidneys filter blood from many arteries, kidney problems are a particular risk for people with diabetes. What is diabetic nephropathy? Nephropathy is a general term for the deterioration of proper functioning in the kidneys. At an advanced level, this is called end-stage renal disease or ESRD. ESRD often stems from diabetes, with diabetes causing just under half of all cases. Diabetic nephropathy can affect people with both type 1 and type 2 diabetes. Diabetic nephropathy is divided into five stages of deterioration, with the final one being ESRD. It commonly takes over 20 years for patients to reach stage 5. Symptoms of kidney disease The symptoms of diabetic nephropathy tend to become apparent once the condition has reached the later stages. Typically the following symptoms may start to be noticed around stage four of its progression: Swelling of the ankles, feet, lower legs or hands caused by retention of water Darker urine, caused by blood in the urine Becoming short of breath, when climbing the stairs for instance Tiredness as a result of a lack of oxygen in the blood Nausea or vomiting To help catch nephropathy before the later stages develop, people with diabetes should be screened for kidney complications once a year. The screening test involves a simple urine sample which is tested to detect whether protein is present in the urine. Read more on kidney disease screening What are the causes of diabetic nephropathy? Statistics show that development of kidney dise Continue reading >>
How Does Ketoacidosis Affect The Human Brain?
Diabetic Ketoacidosis (DKA) is the body’s emergency reaction to glucose starvation in the absence of insulin. It is a disastrous reaction — in general, it makes things worse rather than better, and starts a vicious cycle of blood acidity, rising blood glucose, dehydration, and blood hyperosmolality (high concentration of dissolved stuff) that can be hard to break. One of the hardest-hit organs in DKA is the brain, due to the dehydration and acidic blood entering that sensitive organ. Severe DKA may lead to brain swelling (edema) which is life-threatening. But recent studies have shown that even a short, apparently fully-recovered stint of DKA leads to measurable brain injury. Diabetic Ketoacidosis (DKA) is a life–threatening consequence of diabetes. DKA occurs when there is a lack of insulin in the body causing hyperglycemia. As a result of the inability of glucose to enter the cells, the body must find other means to obtain energy. As such, fat breakdown occurs resulting in the accumulation of fatty acids. The fatty acids are metabolized to ketones that cause the blood to become acidotic (pH less than7.3). Because glucose remains in the blood, there is an increase in thirst and drinking to eliminate the solute load of glucose, which also results in increased urination (polyuria and polydipsia). Thus, the combination of increased serum acidity, weight loss, polyuria, and polydipsia may lead to extreme dehydration, coma, or brain damage. Without a doubt, the most severe acute complication of DKA is cerebral edema. Many cases of new onset type 1 diabetes present DKA (15-70 percent depending on age and geographic region, according to multiple studies), hence the importance of an early diagnosis of diabetes in order to avoid potential consequences. Much research is be Continue reading >>
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 >>
Diabetes And Kidney Damage (nephropathy)
Over time, high blood sugars can cause damage to the kidneys. This is called kidney disease, kidney damage or nephropathy. Your kidneys contain special filters that help clean your blood, remove waste, and control your fluid balance. These filters are called nephrons. Over time, high blood sugar can damage them and cause them to leak protein, called albumin, into your urine. You may experience no symptoms if the damage is minor. However, the extra protein (albumin) can show up on routine blood work conducted by your doctor. Untreated, damage to your kidneys can grow until kidney dialysis or a kidney transplant are necessary. Long-term studies show that achieving your HbA1c targets dramatically lowers your risk for kidney disease.1 The National Institute of Health’s (NIH) Medline Plus center states that kidney damage is more likely to occur if you: Have uncontrolled blood sugar Have high blood pressure Have type 1 diabetes that began before you were 20 years old Have family members who also have diabetes and kidney problems Smoke Are African American, Mexican American, or Native American See your healthcare provider yearly to get tested for any early signs of kidney damage or signs that there could soon be damage to the kidneys. There are different tests available that your healthcare provider should use. Urine albumin test (microalbuminuria): This involves a urine sample which is tested for the presence of a protein called albumin which may leak into the urine from the kidneys. This may indicate the presence of kidney damage. Blood urea nitrogen test (BUN): This involves a sample of blood from a vein and checks kidney function. Serum creatinine: This can be done by urine or blood sample and measures creatinine which should normally be removed by your kidneys so testin Continue reading >>
Diabetes Mellitus And Polyuria
Diabetes comes from the Greek word which means “siphon”. There are two distinct disorders that share the first name diabetes: diabetes mellitus and diabetes insipidus. This is because both disorders cause polyuria, or excessive urine output. Diabetes insipidus is a disorder of urine concentration which we will discuss in spring quarter. Diabetes mellitus is a disorder of blood glucose regulation, which results from a deficiency in the action of the hormone insulin. This may be due to autoimmune destruction of the insulin-secreting cells of the pancreas (type 1 diabetes mellitus) or it may result from a problem in the responsiveness of tissues to insulin, known as insulin resitance (type 2 diabetes mellitus). With either disorder, the result is hyperglycemia, or high levels of glucose in the plasma. How does hyperglycemia cause excessive urine production? To answer this, we need to understand a little bit about how the kidney works. Each kidney contains about a million functional units called nephrons (blue structure in the figure). The first step in the production of urine is a process called filtration (green arrow). In filtration, there is bulk flow of water and small molecules from the plasma into Bowman’s capsule (the first part of the nephron). Because of the nonspecific nature of filtration, useful small molecules such as glucose, amino acids, and certain ions end up in the forming urine, which flows into the kidney tubules. To prevent the loss of these useful substances from the body, the cells lining the kidney tubules use epithelial transport to transfer these substances out of the forming urine and back into the extracellular fluid. This process is known as reabsorption (purple arrows). Under normal circumstances, 100% of the glucose that is filtered is Continue reading >>
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Renal Function And Effects Of Partial Rehydration During Diabetic Ketoacidosis
Although diabetic ketoacidosis is characterized by increased renal excretion of glucose, ketone bodies, and nitrogenous compounds, there are few quantitative studies pertaining to renal function during this state. Therefore, renal function was studied in 10 adult patients in moderate to severe diabetic ketoacidosis before insulin administration. Admission plasma concentrations were: glucose 21.4 (9.2–39.4) mM or 386 (166–710) mg/dl, acetoacetate 3.0 (1.3–7.4) mM, beta-hydroxybutyrate 7.9 (2.9–15.2) mM, acetone 4.4 (1.3–8.9) mM, and HCO3 12.8 (9.5–17.8) mM. Arterial blood pH was 7.28 (7.21–7.38). Partial rehydration was achieved with 0.45% saline. Inulin was used to measure GFR. Renal clearance of acetoacetate, beta-hydroxybutyrate, acetone, glucose, and urinary excretion of nitrogenous compounds were determined. Partial rehydration reduced plasma glucose concentration, primarily because of renal excretion, amounting to 384 ± 73 μmol/min or 69 ± 13 mg/min. Partial rehydration had no effect on plasma ketone bodies, on bicarbonate or urea concentrations, or on arterial pH. Partial rehydration had no effect on ketone body or nitrogenous compound excretory rates. Reabsorptive rates of acetoacetate, beta-hydroxybutyrate, acetone, and glucose increased linearly with their filtered loads, and no maximal renal tubular transport rates were demonstrated for any ketone body or glucose. Because renal absorption of ketone bodies was less than 100%, ketonuria increased as filtered loads increase. Unlike ketone bodies, glucose reabsorptive rate was directly related to GFR. Total renal excretion of nitrogen in the forms of urea, ammonium, creatinine, and uric acid amounted to 16 ± 2 mg/min. This huge loss of body nitrogen reflected ongoing protein catabolism and not he Continue reading >>
I’ll See Your Ketoacidosis And Raise You A Renal Failure
A while back I posted on a paper that appeared in The Lancet about an obese woman who came to the emergency room with gastroenteritis and was misdiagnosed as being in diabetic ketoacidosis (a life-threatening disorder). She was misdiagnosed because the pinheads covering the ER couldn’t get past the fact that she had been on a low-carb diet. At the time I posted on this travesty I noted that this Lancet paper would from here on out be waved in the face of anyone who was following or advocated a low-carb diet as proof that such a diet is dangerous and can cause diabetic ketoacidosis (DKA). Well, now we’ve got an answer. Next time someone tells you that it has been proven that low-carb diets are dangerous and can cause ketoacidosis, you can resort to poker terminology and reply that you’ll see their ketoacidosis and raise them a renal failure. A few days ago I got wind of a paper published a few years ago that can be used as a counterpoint to the above mentioned idiotic paper in The Lancet that has given low-carbers such a bad time. This paper, published in the journal Renal Failure in 1998, is, like the other paper, a case report. The short version is as follows: An obese young man arrived comatose in the emergency room. In an effort to lose weight he had been consuming a high-carbohydrate canned beverage as his sole source of nutrition for the two weeks prior. His blood sugar–at about 20 times normal–was extremely elevated and led to a diagnosis of diabetic ketoacidosis. The physicians on staff treated the patient appropriately, and he, over the next 20 hours or so, regained consciousness as his blood sugar levels and other lab parameters began to normalize. During a lab analysis 22 hours after admission the doctors found the patient to be breaking down and rel Continue reading >>
How Does Diabetes Affect Our Kidneys?
The kidneys filter nearly 200 quarts of our blood every day. Diabetes is a disease of excess sugar in our blood. To remove this excess glucose from the body, the kidneys are under extreme stress and this can easily result in a kidney disorder, called diabetic nephropathy. In 2011, diabetes caused nearly 44% of kidney failure cases. This makes diabetic kidney disease the Number One complication of diabetes; one that is likely to affect almost every diabetic to some extent. In nearly half the cases of kidney disease, it could lead to kidney failure as well. Diabetes damages the kidneys and the urinary system in three main ways: Damage to blood vessels in the kidneys: Too much sugar damages the filters in the kidneys Damage to nerves: Fine nerves in the hands, feet, etc. are corroded by the extra sugar in the blood Damage to the urinary tract: Nerves run from our bladder to our brain and let us know when the bladder is full and we need to go. Damage to these nerves could mean we don’t react when our bladder is full. Result: extra pressure on the kidneys. Retained urine can also allow urinary tract infections to grow and migrate back to the kidneys. Read this excellent article for more info on how diabetes affects kidneys and how to reduce the risks of diabetic nephropathy. Continue reading >>
Editorial Review Diabetic Ketoacidosis: Role Of The Kidney In The Acid-base Homeostasis Re-evaluated
The development of diabetic ketoacidosis (DKA) involves a series of closely interrelated derangements of intermediary metabolism and of body fluid volume and composition whose fundamental nature has not been completely unraveled [1–8]. The composite clinical picture in full-blown DKA on admission includes hyperglycemia with hyperosmolality, metabolic acidosis due to the accumulation of ketoacids, extracellular and intracellular fluid (ECF and ICF, respectively) volume depletion, and varying degrees of electrolyte deficiency, particularly of potassium and phosphate [9–11]. Since proper correction of the alterations in volume status, acid-base, and electrolyte composition is critical for survival, a clear understanding of the pathogenesis of these derangements is essential for the adequate management of DKA. The present review will focus on the role of the kidney in the pathogenesis of the different patterns of electrolyte and acid-base composition observed on admission for and during recovery from DKA. Special emphasis will be placed on the role of the kidney in the defense of acid-base homeostasis during the recovery phase. Other aspects of the alterations that develop in DKA have been reviewed in detail elsewhere [12–14]. Continue reading >>
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: A 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, and 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 flu Continue reading >>
Ketosis & Kidney Failure
Ketosis happens when your body resorts to fat for energy after your stored carbohydrates have been burned out. It often occurs when people fast and exercise. But most commonly, ketosis occurs in people who eat low-carb, high-protein diets, which are also called ketogenic diets. There’s some evidence that ketosis can tax your kidneys, leading to kidney stones and low blood pressure. In diabetics, a variant of ketosis can be fatal. However, a small but growing group of health professionals say ketosis is not the poison you’ve been lead to think it was, and it may be better for you than high-carbohydrate eating. Your specific dietary habits are best advised by your healthcare provider or nutritionist. Video of the Day Ketosis happens when you get a buildup of a substance known as ketones, or ketone bodies in your blood. They are released when your body’s carbohydrate stores run out and you have to break down fat stores for energy. Dieters tend to deliberately cause ketosis because it makes you feel less hungry. However, ketosis also makes you feel tired and sluggish, because as "Medical News Today" reports, ketones aren’t the most efficient source of energy, especially for your brain. Ketosis can also harm your kidneys. Annually, more than 100,000 people are diagnosed with kidney failure in the United States, reports the National Institute of Diabetes and Digestive and Kidney Diseases, or NIDDK. The condition is marked by the inability of your kidneys to do their job of eliminating wastes. One treatment for kidney failure is dialysis, a draining and lengthy artificial blood cleansing process. Another option is a kidney transplant. The NIDDK states that the cost of care for patients with kidney failure reached close to $32 billion in 2005. The federal government sub Continue reading >>
Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus.[1] Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and occasionally loss of consciousness.[1] A person's breath may develop a specific smell.[1] Onset of symptoms is usually rapid.[1] In some cases people may not realize they previously had diabetes.[1] DKA happens most often in those with type 1 diabetes, but can also occur in those with other types of diabetes under certain circumstances.[1] Triggers may include infection, not taking insulin correctly, stroke, and certain medications such as steroids.[1] DKA results from a shortage of insulin; in response the body switches to burning fatty acids which produces acidic ketone bodies.[3] DKA is typically diagnosed when testing finds high blood sugar, low blood pH, and ketoacids in either the blood or urine.[1] The primary treatment of DKA is with intravenous fluids and insulin.[1] Depending on the severity, insulin may be given intravenously or by injection under the skin.[3] Usually potassium is also needed to prevent the development of low blood potassium.[1] Throughout treatment blood sugar and potassium levels should be regularly checked.[1] Antibiotics may be required in those with an underlying infection.[6] In those with severely low blood pH, sodium bicarbonate may be given; however, its use is of unclear benefit and typically not recommended.[1][6] Rates of DKA vary around the world.[5] In the United Kingdom, about 4% of people with type 1 diabetes develop DKA each year, while in Malaysia the condition affects about 25% a year.[1][5] DKA was first described in 1886 and, until the introduction of insulin therapy in the 1920s, it was almost univ Continue reading >>
Bladder & Kidneys
Kidney and bladder damage is a complication of diabetes. People with diabetes are at risk of bladder and kidney infections, kidney failure and dialysis Maintaining good blood glucose control and keeping your blood pressure at a healthy level will reduce this risk Annual kidney health checks are recommended Kidney Disease Kidney disease occurs when the nephrons inside your kidneys, which act as blood filters, are damaged. This leads to the build up of waste and fluids inside the body. If kidney disease is not diagnosed, it can lead to serious complications including kidney failure, which requires dialysis or a kidney transplant to keep you alive. Kidney disease and diabetes Each kidney contains up to one million nephrons, the filtering units of the kidneys. Inside a nephron is a tiny set of looping blood vessels called the glomerulus. Diabetes can damage the kidney filters, leading to diabetic kidney disease, or diabetic nephropathy. If kidney disease is found early, medication, dietary and lifestyle changes can increase the life of your kidneys and keep you feeling your best for as long as possible. Symptoms In some cases diabetic kidney disease causes the kidney filters to become blocked and stop working, which results in kidney failure. Symptoms of kidney failure may be general and can include: changes in the amount and number of times urine is passed blood in the urine tiredness loss of appetite difficulty sleeping headaches lack of concentration shortness of breath nausea and vomiting Controlling blood sugar levels can slow down the development of diabetic kidney disease. Kidney health check It is very important that diabetic kidney disease is detected early as treatment can help to increase the life of the kidneys. Your health care team can give you practical advic Continue reading >>
