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

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.

Download Full-text

Methemoglobinemia-Induced Acute Kidney Injury

The Open Urology & Nephrology Journal ◽

10.2174/1874303x01306010036 ◽

2013 ◽

Vol 6 (1) ◽

pp. 36-41 ◽

Cited By ~ 2

Author(s):

Amir H. Qureshi ◽

Daniel J. Soberon ◽

Arif Asif ◽

Tushar Vachharajani ◽

Ali Nayer

Keyword(s):

Acute Kidney Injury ◽

Renal Function ◽

Renal Biopsy ◽

Case Reports ◽

Kidney Injury ◽

Human Case ◽

Morphological Features ◽

Chronic Obstructive ◽

Tubular Damage ◽

Obstructive Pulmonary Disease

IntroductionMethemoglobinemia refers to the presence of increased levels of methemoglobin (Fe3+) in the blood. Methemoglobinemia can cause cyanosis, dyspnea, fatigue, seizure, arrhythmia, coma, and even death. Although methemoglobinemia is shown to cause acute kidney injury in experimental settings, human case reports are exceedingly rare. In addition, morphological features of methemoglobinemia-induced renal disease in humans remain undefined.Case PresentationA 76-year-old man with a history of chronic obstructive pulmonary disease underwent bronchoscopy following local anesthesia with a benzocaine spray. The patient developed benzocaine-induced methemoglobinemia and acute renal failure. Urinalysis disclosed numerous dysmorphic erythrocytes, erythrocyte casts, and granular casts. Urine protein excretion was approximately 1.1 g/day. Serologic tests were negative. Renal biopsy demonstrated minor glomerular abnormalities, severe acute tubular necrosis, and numerous erythrocyte casts in the tubules. Despite supportive care, renal function deteriorated necessitating hemodialysis. Four months later, the patient remained on hemodialysis. To exclude a superimposed pathology, renal biopsy was repeated and showed numerous erythrocyte casts in the tubules and severe tubular damage.ConclusionMethemoglobinemia can cause acute kidney injury in humans. Morphological features resemble those observed in methemoglobin-induced acute kidney injury in experimental settings. This case calls for a heightened awareness of potential adverse effects of methemoglobinemia on renal function.

Download Full-text

Acute Kidney Injury among Adult Patients with Diabetic Ketoacidosis in a Referral Hospital of Bangladesh

BIRDEM Medical Journal ◽

10.3329/birdem.v8i1.35035 ◽

2017 ◽

Vol 8 (1) ◽

pp. 26-29

Author(s):

Muhammad Abdur Rahim ◽

Mehruba Alam Ananna ◽

Tabassum Samad ◽

Shahana Zaman ◽

Rozana Rouf ◽

...

Keyword(s):

Acute Kidney Injury ◽

Acute Pancreatitis ◽

Diabetic Ketoacidosis ◽

Low Income ◽

Kidney Injury ◽

Income Group ◽

Acute Kidney Injury Network ◽

Medical Emergency ◽

Diabetic Patients ◽

Cross Sectional

Background: Diabetic ketoacidosis (DKA) is a medical emergency. DKA may be complicated by acute kidney injury (AKI) and may require renal replacement therapy. Early detection and treatment including treatment of underlying cause and complication(s), if present, is important in determining outcome of DKA. This study was designed to evaluate the incidence of AKI among patients with DKA.Methods: This cross-sectional study was done in BIRDEM General Hospital, Dhaka, Bangladesh from 2008 to 2011. AKI was diagnosed by using acute kidney injury network (AKIN) criteria.Results: Total patients were 200 with slight female predominance (56%). Mean age of the study subjects was 37.6±7.5 years. Incidence of DKA was more in known diabetic patients (71%), more among rural population (53%) and low income group (76.5%). Infection (40.5%) was the commonest precipitating cause followed by non-adherence to insulin therapy (31%). Acute pancreatitis (5%), myocardial infarction (2%), stroke (1%) and surgery (1.5%) were less common causes and aetiology could not be identified in 14% cases. Fifty nine (29.5%) cases were complicated by AKI and among them three (5%) patients required haemodialysis. AKI was more in severe DKA (pH <7) cases and when precipitated by acute pancreatitis and infections. In spite of standard management overall mortality was 6.5%.Conclusion: Almost one-third of DKA cases had AKI in this study, more in DKA cases precipitated by acute pancreatitis and sepsis. Fluid resuscitation resolved AKI in most cases but few cases required renal replacement therapy.Birdem Med J 2018; 8(1): 26-29

Download Full-text

Tenofovir alafenamide nephrotoxicity: a case report and literature review

AIDS Research and Therapy ◽

10.1186/s12981-021-00380-w ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Thornthun Ueaphongsukkit ◽

Sivaporn Gatechompol ◽

Anchalee Avihingsanon ◽

Jerasit Surintrspanont ◽

Kroonpong Iampenkhae ◽

...

Keyword(s):

Acute Kidney Injury ◽

Renal Function ◽

Case Reports ◽

Kidney Injury ◽

Hiv Treatment ◽

Preventive Strategy ◽

Chronic Hepatitis B Infection ◽

Essential Information ◽

Sporadic Cases ◽

Tenofovir Alafenamide

Abstract Background Tenofovir alafenamide (TAF), a novel prodrug of tenofovir (TFV), has become the preferred drug for the treatment of HIV-1 and chronic hepatitis B infection in clinical practice. Results from clinical trials showed that it had better renal and bone mineral outcomes compared to tenofovir disoproxil fumarate (TDF). However, as we have seen with TDF, side effects from the new medication can be more prevalent and recognized after extensive use in real world situations. Sporadic cases of acute kidney injury in patients using TAF have started to emerge. Case presentation We report a case of 49-year-old Thai, HIV treatment-experienced female with hypertension presented with worsening renal function after switching her antiretroviral regimen from TDF, emtricitabine (FTC), and lopinavir/ritonavir (LPV/r) to TAF, FTC and dolutegravir (DTG) for 3 months. Kidney biopsy showed distinctive picture of tenofovir nephrotoxicity with acute tubular injury and mitochondrial injury. The possible causes of acute kidney injury and nephrotoxicity from TAF for this patient were discussed. We have extensively reviewed all published case reports of TAF-associated nephrotoxicity and summarized the essential information in this article. Conclusion Although TAF has less nephrotoxicity compared with TDF; renal function should always be monitored after the initiation of both drugs. Future large cohort studies are required to identify the risk factors of TAF-associated nephrotoxicity and to design an effective preventive strategy.

Download Full-text

Acute kidney injury associated with ingestion of star fruit: Acute oxalate nephropathy: a report of two cases

Community Based Medical Journal ◽

10.3329/cbmj.v8i2.55773 ◽

2019 ◽

Vol 8 (2) ◽

pp. 47-51

Author(s):

Mahmud Javed Hasan ◽

Nitai Chandra Ray ◽

Shaikh Shariful Islam ◽

Shakil Azam Nahid ◽

Tumpa Shom ◽

...

Keyword(s):

Acute Kidney Injury ◽

Renal Function ◽

Normal Renal Function ◽

Herbal Remedy ◽

Case Reports ◽

Kidney Injury ◽

Young Male ◽

Empty Stomach ◽

Star Fruit ◽

History Of

There are few case reports regarding star fruit's nephrotoxicity and neurotoxicity in chronic kidney disease patients. Star fruit (Averrhoa carambola) is commonly consumed as a herbal remedy for various ailments in tropical countries. However, the dangers associated with consumption of star fruit are not commonly known. Although star fruit induced oxalate nephrotoxicity in those with existing renal impairment is well documented, reports on its effect on those with normal renal function are infrequent. We report two unique clinical presentation patterns of star fruit nephrotoxicity following consumption of the fruit. The first patient is a 52 year-old male diabetic patient who had normal renal function prior to developing acute kidney injury (AKI) after consuming large amount of star fruit juice at once for remedy of diabetes. The second patient, a 27 years old young male who developed acute kidney injury following star fruit ingestion in empty stomach. One case needed 4 sessions of hemodialysis another case recovered over 2 weeks without the need for haemodialysis. Consumption of star fruit, especially on an empty stomach or in a state of dehydration may precipitate acute kidney injury. A history of star fruit ingestion must be actively looked for in patients presenting with unexplained acute kidney injury. The use of star fruit as a therapy for diabetes should be discouraged. CBMJ 2019 July: Vol. 08 No. 02 P: 47-51

Download Full-text

Risk for acute kidney injury in primary health care

Revista Brasileira de Enfermagem ◽

10.1590/0034-7167-2016-0551 ◽

2018 ◽

Vol 71 (1) ◽

pp. 20-25 ◽

Cited By ~ 1

Author(s):

Maria Célia Laranjeira Rigonatto ◽

Marcia Cristina da Silva Magro

Keyword(s):

Health Care ◽

Acute Kidney Injury ◽

Renal Function ◽

Primary Health Care ◽

Renal Injury ◽

Kidney Injury ◽

Total Sample ◽

Diabetic Patients ◽

Primary Health ◽

Spearman Test

ABSTRACT Objective: To identify hypertensive and diabetic patients at risk for developing acute kidney injury in the primary health care setting. Method: Observational, longitudinal, prospective study. Sample of 56 diabetic and hypertensive individuals. A semi-structured questionnaire was adopted for data collection. For the description of results, were calculated dispersion measures and the Spearman test was used for statistical analysis. The result was considered significant when p <0.05. Results: Of the total sample, 23.2% of users evolved with renal impairment, of which 19.6% with risk for renal injury, and 3.6% with kidney injury itself. Age and body mass index were associated with worsening of renal function (p = 0.0001; p = 0.0003), respectively. Conclusion: A quarter of the health system users, hypertensive and diabetic, evolved with impaired renal function, more specifically to stages of risk for renal injury and kidney injury according to the RIFLE classification.

Download Full-text

Acute kidney injury strongly influences renal function after radical nephroureterectomy for upper tract urothelial carcinoma: A single-centre experience

Archivio Italiano di Urologia e Andrologia ◽

10.4081/aiua.2021.1.9 ◽

2021 ◽

Vol 93 (1) ◽

pp. 9-14

Author(s):

Alessandro Tafuri ◽

Katia Odorizzi ◽

Giacomo Di Filippo ◽

Clara Cerrato ◽

Giulia Fassio ◽

...

Keyword(s):

Acute Kidney Injury ◽

Renal Function ◽

Multivariate Analysis ◽

Serum Creatinine ◽

Urothelial Carcinoma ◽

Clinical Evaluation ◽

Kidney Injury ◽

Radical Nephroureterectomy ◽

Clinical Factors ◽

Renal Function Decline

Objective: The aim of our study was to investigate frequency and predictors both of postoperative acute kidney injury (AKI) and renal function decline in a population of consecutive upper tract urothelial carcinoma (UTUC) patients who underwent radical nephroureterectomy (RNU). Materials and methods: Between October 2014 and February 2020, 93 patients underwent RNU at our Institution. After considered exclusion criteria, 89 patients were selected. Perioperative clinical factors were retrospectively collected. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) equation. We defined AKI as an increase in serum creatinine by ≥ 0.3 mg/dl or a 1.5-1.9-fold increase in serum creatinine from baseline to I post-operative day (POD). A significant renal function reduction was defined as an eGFR reduction of 40% from baseline at discharge and at last clinical evaluation. Frequency of AKI and eGFR decline was investigated. Association between perioperative clinical factors and AKI and eGFR reduction at discharged and last follow-up was studied using univariate and multivariate models. Results: AKI was detected at I POD in 45 patients. On multivariate analysis, pre-operative eGFR was an independent predictor of AKI (OR 1.03; p = 0.042). Further, AKI was found to be a significant predictor of eGFR reduction ≥ 40% at discharge at univariate analysis (OR 19.42; p = 0.005) and at multivariate analysis (OR 12.49; p = 0.02). In a multivariate logistic regression model post-operative AKI (OR 5.18; p = 0.033), lack of ipsilateral preoperative hydronephrosis (OR 0.17; p = 0.016), preoperative eGFR (OR 1.04; p = 0.047) and antiplatelet therapy (OR 5.14; p = 0.018) were found to be independent predictors of an eGFR reduction higher than 40% at last clinical evaluation made at a median of 15 (IQR 5-30) months. Conclusions: In our cohort, AKI was present in almost 50% of patients after RNU and it was a strong predictor of renal function decline after RNU.

Download Full-text

Acute kidney injury caused by ammonium acid urate crystals in diabetic ketoacidosis at the onset of type 1 diabetes mellitus

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-20-0143 ◽

2021 ◽

Vol 2021 ◽

Author(s):

Shunsuke Shimazaki ◽

Itsuro Kazukawa ◽

Kyoko Mori ◽

Makiko Kihara ◽

Masanori Minagawa

Keyword(s):

Acute Kidney Injury ◽

Diabetic Ketoacidosis ◽

Urine Volume ◽

Kidney Injury ◽

Recovery Phase ◽

List Type ◽

Volume Depletion ◽

Urine Sediment ◽

Ammonium Acid Urate ◽

Urate Crystals

Summary Ammonium acid urate (AAU) crystals are rare in industrialized countries. Furthermore, the number of children with diabetic ketoacidosis (DKA) who develop severe acute kidney injury (AKI) after hospitalization is small. We encountered two patients with AKI caused by AAU crystals during the recovery phase of DKA upon admission. They were diagnosed with severe DKA and hyperuricemia. Their urine volume decreased and AKI developed several days after hospitalization; however, acidosis improved in both patients. Urine sediment analysis revealed AAU crystals. They were treated with urine alkalization and diuretics. Excretion of ammonia in the urine and urine pH levels increased after treatment of DKA, which resulted in the formation of AAU crystals. In patients with severe DKA, the urine and urine sediment should be carefully examined as AAU can form in the recovery phase of DKA. Learning points Ammonium acid urate crystals could be formed in the recovery phase of diabetic ketoacidosis. Diabetic ketoacidosis patients may develop acute kidney injury caused by ammonium acid urate crystals. Urine and urine sediment should be carefully checked in patients with severe DKA who present with hyperuricemia and volume depletion.

Download Full-text

COVID-19 and emergencies in patients with diabetes: two case reports

Journal of Medical Case Reports ◽

10.1186/s13256-020-02659-4 ◽

2021 ◽

Vol 15 (1) ◽

Author(s):

Rajib Kumar Dey ◽

Abdullah Isneen Hilmy ◽

Hisham Ahmed Imad ◽

Abdul Azeez Yoosuf ◽

Ali Abdulla Latheef

Keyword(s):

Acute Kidney Injury ◽

Case Reports ◽

Kidney Injury ◽

Diabetic Patients ◽

Close Monitoring ◽

Case Presentation ◽

Uncontrolled Diabetes ◽

Patients With Diabetes ◽

Hyperosmolar Hyperglycemic State ◽

Asian Male

Abstract Background Maldives reported its first Coronavirus disease 2019 (COVID-19) case on March 7th, 2020. Since then more than 9400 positive cases and 33 deaths have been reported. Recently studies have shown that COVID-19 patients with diabetes had a poor prognosis and a higher mortality rate when compared to the non-diabetic patients. Poorly controlled diabetic patients had a higher incidence of complications like diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) which might have been precipitated by COVID-19. DKA and HHS are potentially lethal but preventable conditions. During this pandemic, although cases of uncontrolled diabetes are frequently reported, there is scarcity in reporting of cases with diabetic emergencies. Case presentation Case 1 was a 53-year old Asian male, admitted on Day 10th of illness with DKA with acute kidney injury, and Moderate COVID-19. Case 2 was a 72-year old Asian male, admitted with mild COVID-19 who developed HHS with acute kidney injury on day 9 of illness. Both patients were managed conservatively in intensive care unit, with intravenous fluids and insulin. Conclusion Clinicians should focus on close monitoring of diabetic patients with COVID-19, to prevent diabetic emergencies like DKA and HHS. It is important to aggressively manage these conditions for a favorable outcome.

Download Full-text

Star fruit intoxication leading to acute kidney injury

Bangladesh Medical Journal Khulna ◽

10.3329/bmjk.v48i1-2.27099 ◽

2016 ◽

Vol 48 (1-2) ◽

pp. 37-39 ◽

Cited By ~ 1

Author(s):

Md Arshad Ul Azim ◽

Abdus Salam

Keyword(s):

Chronic Kidney Disease ◽

Acute Kidney Injury ◽

Renal Function ◽

Kidney Disease ◽

Normal Renal Function ◽

Case Reports ◽

Kidney Injury ◽

Young Male ◽

Star Fruit ◽

Oxalate Nephropathy

There are few case reports regarding star fruit's nephrotoxicity and neurotoxicity in chronic kidney disease patients. Recently cases are found in people with normal renal function Star fruit nephrotoxicity is believed to be due to its high oxalate content which causes acute obstructive oxalate nephropathy. A neurotoxin (caramboxin) present in the fruit is responsible for neurotoxic features. Here we present a young male who developed acute kidney injury following star fruit ingestion in empty stomach. After admission, patient was treated conservatively and recovered completely.Bang Med J (Khulna) 2015; 48 : 37-39

Download Full-text