Diabetic ketoacidosis in the dialysis-dependent patient: two case reports and recommendations for treatment

Diabetic ketoacidosis (DKA) is a life-threatening metabolic derangement, defined by the presence of severe hyperglycaemia, ketosis and metabolic acidosis. Recently, DKA was redefined to be present when the latter two abnormalities occur without severe hyperglycaemia. Munro and colleagues in Edinburgh described ‘euglycaemic diabetic ketoacidosis’ in 1973 and suggested this new terminology. The same year the critical feature of this subclass of DKA – that is, an increased urinary loss of glucose – was identified by Ireland and Thomson in Glasgow. In the subsequent 40 years (from 1974 to 2014), clinical interest in this condition was limited to a few case reports. The emergence of a new class of antidiabetes medications, the sodium-glucose cotransporter (SGLT) inhibitors, which promote profuse glycosuria, has reawakened interest in euglycaemic DKA, as this is a side effect of these drugs. The earlier perceptive observations of these physicians in Scotland deserve to be recognised for their contribution in identifying and describing euglycaemic DKA and correctly identifying its underlying pathogenesis. Recent international consensus has provided guidance to physicians to aid timely recognition of the condition by testing for ketosis in the appropriate clinical context and to manage it effectively by discontinuing the SGLT inhibitor and provision of insulin, carbohydrate and hydration (the STICH protocol). This may be particularly relevant in view of the recent licensing developments for use of certain members of the SGLT inhibitors in type 1 diabetes.

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Euglycemic Diabetic Ketoacidosis in Pregnancy: A Case Report and Review of Current Literature

Case Reports in Critical Care ◽

10.1155/2019/8769714 ◽

2019 ◽

Vol 2019 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Johnny F. Jaber ◽

Matthew Standley ◽

Raju Reddy

Keyword(s):

Blood Glucose ◽

Diabetic Ketoacidosis ◽

Case Reports ◽

Anion Gap ◽

Fetal Mortality ◽

Glucose Levels ◽

Elevated Glucose ◽

High Doses ◽

Euglycemic Diabetic Ketoacidosis ◽

In Pregnancy

Diabetic ketoacidosis (DKA) in pregnancy is associated with high fetal mortality rates. A small percentage of DKA occurs in the absence of high glucose levels seen in traditional DKA. Prompt recognition and management is crucial. We report a case of a 30-year-old pregnant woman with type 1 diabetes mellitus admitted with euglycemic DKA (blood glucose <200 mg/dL). Initial laboratory testing revealed a severe anion gap acidosis with pH 7.11, anion gap 23, elevated β-hydroxybutyric acid of 9.60 mmol/L, and a blood glucose of 183 mg/dL—surprisingly low given her severe acidosis. The ketoacidosis persisted despite high doses of glucose and insulin infusions. Due to nonresolving acidosis, her hospital course was complicated by spontaneous intrauterine fetal demise. Euglycemia and severe acidosis continued to persist until delivery of fetus and placenta occurred. It was observed that the insulin sensitivity dramatically increased after delivery of fetus and placenta leading to rapid correction of ketoacidosis. This case highlights that severe ketonemia can occur despite the absence of severely elevated glucose levels. We discuss the mechanism that leads to this pathophysiologic state and summarize previously published case reports about euglycemic DKA in pregnancy.

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345. Acute Onset Diabetic Ketoacidosis/Hyperosmolar Hyperglycemic State in Patients Taking Integrase Strand Transfer Inhibitors

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.418 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S183-S184 ◽

Cited By ~ 1

Author(s):

Afua Duker Ntem-Mensah ◽

Nina Millman ◽

Niyati Jakharia ◽

Amanda Theppote ◽

Mona-Gekanju Toeque ◽

...

Keyword(s):

Weight Gain ◽

Blood Glucose ◽

Blood Glucose Level ◽

Diabetic Ketoacidosis ◽

Glucose Level ◽

Case Reports ◽

Acute Onset ◽

Anion Gap ◽

Hyperosmolar Hyperglycemic State ◽

Hba1c Levels

Abstract Background A few case reports have noted uncontrolled hyperglycemia in patients switched to dolutegravir. Several cohort studies have found increased weight gain among patients treated with integrase inhibitors (INSTI). We present clinical observations among 3 patients admitted to hospital for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) while receiving INSTIs for the management of HIV. Methods Case 1: A 44-year-old man with HIV and dyslipidemia presented with altered mental status and lethargy. A fingerstick glucose was >600 mg/dL. Chemistries revealed glucose of 1,600 mg/dL and an elevated β-hydroxybutyrate. HbA1c was 12.4%. His antiretroviral regimen consisted of cEVG/TAF/FTC for the last 3 years. Previous HbA1c levels were 5.7% and 6.2% (Figure 1). Case 2: A 55-year-old woman with HIV, hypertension, dyslipidemia, and obesity presented with polyuria and polydipsia. The blood glucose level was >1,200 mg/dL with an anion gap >30 and HbA1c of 15%. Previous HbA1c levels ranged between 5.6 and 5.8% (Figure 2). She had been taking ABC/FTC/DTG for 2 years. Case 3: A 64 yo man with a history of HIV, hypertension, and obesity presented with polyuria and polydipsia. The blood glucose level was 1,152 mg/dL with no anion gap and HbA1c of 13.4%. Six months before, he had been switched from a c/DRV- based ART regimen to ABC/FTC/DTG. Previous HbA1c levels ranged between 5.8% and 6.2% (Figure 3). Results Discussion: In the first 2 patients, the presentation with acute onset DKA occurred more than a year after being on an INSTI-based regimen; however, the latter patient presented with HHS within 6 months of being switched to an INSTI-containing regimen. The mechanism of action of INSTIs causing weight gain or an association with hyperglycemia is still under investigation. Conclusion Although the temporal onset of DKA and HHS while receiving INSTIs was not precise, the possible association of INSTIs and their direct effects on insulin resistance and diabetes warrant additional attention from post-market data. Meanwhile, providers should monitor INSTI-treated patients closely, especially those with features of metabolic syndrome. Disclosures All authors: No reported disclosures.

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Euglycemic Diabetic Ketoacidosis Associated With Sodium–Glucose Cotransporter Type 2 Inhibitors in Patients With Type 2 Diabetes Mellitus Receiving Oral Therapy

Journal of Pharmacy Practice ◽

10.1177/0897190017748049 ◽

2017 ◽

Vol 32 (2) ◽

pp. 240-243 ◽

Cited By ~ 3

Author(s):

Ryan B. Dull ◽

Mikayla L. Spangler ◽

Emily L. Knezevich ◽

Britney M. Lau

Keyword(s):

Diabetes Mellitus ◽

Type 2 Diabetes ◽

Type 2 Diabetes Mellitus ◽

Diabetic Ketoacidosis ◽

Case Reports ◽

Serious Adverse Events ◽

Type 2 Dm ◽

Sodium Glucose Cotransporter ◽

Increased Risk

Introduction and Objective: Postmarketing reports and warnings of serious adverse events such as diabetic ketoacidosis (DKA) have raised concern regarding the safety of sodium–glucose cotransporter 2 inhibitors (SGLT2i). This report describes 2 cases of symptomatic SGLT2i-associated euglycemic DKA (euDKA) leading to hospitalization in patients with type 2 diabetes mellitus (DM) previously well controlled on oral medications. Case Reports: Subject 1 is a 55-year-old female admitted with euDKA precipitated by infection and managed with intravenous insulin. This case was notable for a delayed diagnosis of euDKA and lack of clinical improvement despite withholding dapagliflozin. Subject 2 is a 62-year-old male admitted with euDKA precipitated by infection. His clinical condition improved rapidly and euDKA responded to withdrawal of empagliflozin alone. Discussion: Applying the Naranjo adverse medication reaction probability scale to each case (subject 1 score = 3 points; subject 2 score = 4 points) suggests these are possible adverse reactions to SGLT2i. Data from randomized controlled trials suggest DKA events in adults with type 2 DM receiving SGLT2i are rare and similar to placebo. However, data from a large cohort suggest these events occur more frequently and are associated with a 2-fold increased risk of DKA. Conclusion: This class of medications may be associated with a higher real-world risk of DKA in adults with type 2 DM than previously reported. Patients prescribed these medications should receive vigilant assessment for features of traditional DKA as well as euDKA.

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Diabetic Ketoacidosis as First Presentation of Latent Autoimmune Diabetes in Adult

Case Reports in Medicine ◽

10.1155/2015/821397 ◽

2015 ◽

Vol 2015 ◽

pp. 1-3 ◽

Cited By ~ 2

Author(s):

Omar Nadhem ◽

Essam Nakhla ◽

Roger D. Smalligan

Keyword(s):

Diabetic Ketoacidosis ◽

Age Of Onset ◽

Autoimmune Diabetes ◽

Case Reports ◽

White Female ◽

Acid Decarboxylase ◽

Insulin Independence ◽

Adult Age ◽

Latent Autoimmune Diabetes ◽

Diabetic Education

A 54-year-old white female with hypothyroidism presented with abdominal pain, nausea, vomiting, and diarrhea. She was found to have diabetic ketoacidosis (DKA) and admitted to our hospital for treatment. Laboratory workup revealed positive antiglutamic acid decarboxylase antibodies and subsequently she was diagnosed with latent onset autoimmune diabetes in adult (LADA). She was successfully treated with insulin with clinical and laboratory improvement. Diagnosis of LADA has been based on three criteria as given by The Immunology of Diabetes Society: (1) adult age of onset (>30 years of age); (2) presence of at least one circulating autoantibody (GADA/ICA/IAA/IA-2); and (3) initial insulin independence for the first six months. The importance of this case is the unlikely presentation of LADA. We believe that more research is needed to determine the exact proportion of LADA patients who first present with DKA, since similar cases have only been seen in case reports. Adult patients who are obese and have high blood sugar may deserve screening for LADA, especially in the presence of other autoimmune diseases. Those patients once diagnosed with LADA need extensive diabetic education including potentially serious events such as diabetic ketoacidosis.

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404: COMPLICATIONS OF DIABETIC KETOACIDOSIS IN A PACEMAKER-DEPENDENT PATIENT

Critical Care Medicine ◽

10.1097/01.ccm.0000807940.82547.33 ◽

2021 ◽

Vol 50 (1) ◽

pp. 190-190

Author(s):

Amit Mehta ◽

Matthew Hudkins

Keyword(s):

Diabetic Ketoacidosis ◽

Dependent Patient

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Diabetic Ketoacidosis Precipitated by COVID-19 in Patients Without Respiratory Symptoms: Case Reports

Cureus ◽

10.7759/cureus.10031 ◽

2020 ◽

Cited By ~ 1

Author(s):

Jose L Meza ◽

Abel Triana ◽

Ivan De Avila ◽

Gaspar Del Rio-Pertuz ◽

Diego Viasus

Keyword(s):

Diabetic Ketoacidosis ◽

Respiratory Symptoms ◽

Case Reports

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DIABETIC KETOACIDOSIS ASSOCIATED WITH ANTIPSYCHOTIC DRUGS: CASE REPORTS AND A REVIEW OF LITERATURE

Psychiatria Danubina ◽

10.24869/psyd.2017.121 ◽

2017 ◽

Vol 29 (2) ◽

pp. 121-135 ◽

Cited By ~ 17

Author(s):

Antonia Vuk ◽

◽

Martina Rojnic Kuzman ◽

Maja Baretic ◽

Martina Matovinovic Osvatic ◽

...

Keyword(s):

Diabetic Ketoacidosis ◽

Antipsychotic Drugs ◽

Case Reports ◽

Review Of Literature

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Mortality of Diabetes-related Acute Metabolic Emergencies in COVID-19 patients: a systematic review and meta-analysis

10.1101/2021.01.12.21249697 ◽

2021 ◽

Author(s):

Vasileios P. Papadopoulos ◽

Peny Avramidou ◽

Stefania-Aspasia Bakola ◽

Dimitra-Geogia Zikoudi ◽

Ntilara Touzlatzi ◽

...

Keyword(s):

Systematic Review ◽

Mortality Rate ◽

Diabetic Ketoacidosis ◽

Critical Appraisal ◽

Case Reports ◽

Meta Analysis ◽

Random Effects Model ◽

Inclusion Criteria ◽

Cross Sectional ◽

Meta Analyses

AbstractPurposeLittle is known on the mortality rate in COVID-19 related acute metabolic emergencies, namely diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS), combined DKA/HHS, and euglycaemic diabetic ketoacidosis (EDKA).MethodsA systematic literature review was conducted using EMBASE, PubMed/Medline, and Google Scholar from January 1, 2020 to January 9, 2021 to identify all case report series, cross-sectional studies, and meta-analyses of case reports describing mortality rate in DKA, HHS, and EDKA, in COVID-19 patients. The Joanna Briggs Institute critical appraisal checklist for case reports was used for quality assessment.ResultsFrom 313 identified publications, 4 fulfilled the inclusion criteria and analyzed qualitatively and quantitatively. A systematic review and meta-analysis with subgroup analyses examined mortality rate in a total of 152 COVID-19 patients who had developed DKA, HHS, combined DKA/HHS, or EDKA. Combined mortality rate and confidence intervals (CI) were estimated using random effects model. The study was registered to PROSPERO database (ID: 230737).ResultsCombined mortality rate was found to be 27.1% [95% CI: 11.2-46.9%]. Heterogeneity was considerable (I2=83%; 95% CI: 56-93%), corrected to 67% according to Von Hippel adjustment for small meta-analyses. Funnel plot presented no apparent asymmetry; Egger’s and Begg’s test yielded in P=0.44 and P=0.50, respectively. Sensitivity analysis failed to explain heterogeneity.ConclusionCOVID-19 related acute metabolic emergencies (DKA, HHS, and EDKA) are characterized by considerable mortality; thus, clinicians should be aware of timely detection and immediate treatment commencing.

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Acute Metabolic Emergencies in Diabetes and COVID-19: a systematic review and meta-analysis of case reports

10.1101/2021.01.10.21249550 ◽

2021 ◽

Author(s):

Vasileios Papadopoulos ◽

Marios-Vasileios Koutroulos ◽

Dimitra-Georgia Zikoudi ◽

Stefania-Aspasia Bakola ◽

Peny Avramidou ◽

...

Keyword(s):

Acute Kidney Injury ◽

Renal Function ◽

Multivariate Analysis ◽

Diabetic Ketoacidosis ◽

Case Reports ◽

Kidney Injury ◽

Previous Treatment ◽

Anion Gap ◽

Diabetic Patients ◽

List Type

AbstractBackgroundCOVID-19 is associated with DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and EDKA (Euglycaemic DKA). High mortality has been observed in COVID-19-related diabetic ketoacidosis; however, evidence is scarce.MethodsA systematic literature review was conducted using EMBASE, PubMed/Medline, and Google Scholar from January to December 2020 to identify all case reports describing DKA, HHS, and EDKA, in COVID-19 patients. The Joanna Briggs Institute critical appraisal checklist for case reports was used for quality assessment. Univariate and multivariate analysis assessed correlations of study origin, combined DKA/HHS, age, BMI, HbA1c, administered antidiabetics, comorbidities, symptoms onset, disease status (DS), CRP, ferritin, d-dimers, glucose, osmolarity, pH, bicarbonates, ketones, lactates, β-hydroxybutyric acid, anion gap, and acute kidney injury (AKI) with outcome. The relevant protocol was submitted to PROSPERO database (ID: 229356).ResultsFrom 312 identified publications, 41 including 71 cases analyzed qualitatively and quantitatively. The types of acute metabolic emergencies observed were DKA (45/71, 63.4%), EDKA (6/71, 8.5%), combined DKA/HHS (19/71, 26.8%), and HHS (1/71, 1.4%). Overall mortality was 32.4% (22/68 patients; 3 missing). Multivariate analysis by classical regression demonstrated that COVID-19 DS4 (P=3•10−8), presence of DKA/HHS (P=0.021), and development of AKI (P=0.037) were all independently correlated with death. Increased DS (P=0.003), elevated lactates (P<0.001), augmented anion gap (P<0.001), and presence of AKI (P=0.002) were associated with DKA/HHS. SGLT-2i administration was linked with EDKA (P=0.004); however, a negative association with AKI was noted (P=0.023).ConclusionCOVID-19 intertwines with acute metabolic emergencies in diabetes leading to increased mortality. Key determinants are critical COVID-19 illness, coexistence of DKA/HHS and AKI. Awareness of clinicians to timely assess them might enable early detection and immediate treatment commencing. As previous treatment with was negatively associated with AKI, thus implying a prophylactic effect on renal function, the issue of discontinuation of SGLT-2i in COVID-19 patients remains to be further evaluated.Key messagesWhat is already known on this subject▸Diabetes mellitus (DM) is a risk factor for poor outcomes in COVID-19 patients.▸Diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) are not rare in COVID-19 diabetic and non-diabetic patients; key determinants of outcome remain unknown.What this study adds▸COVID-19 intertwines with acute metabolic emergencies in diabetes leading to increased mortality; key determinants are critical COVID-19 illness, coexistence of DKA and HHS as well as development of acute kidney injury.▸SGLT2-i administration is linked with euglycaemic DKA in patients with COVID-19, though preserving renal function.

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