Sepsis-Induced Diabetic Ketoacidosis (DKA) in Latent Autoimmune Diabetes in Adult (LADA)

Backgrounds. Latent autoimmune diabetes in adults (LADA) is a slowly progressive form of autoimmune diabetes mellitus characterized by older age at diagnosis, presence of pancreatic autoantibodies, and lack of absolute insulin requirement at diagnosis. Patients with LADA had better β-cell function than patients with classic Type 1 DM (T1DM). Overtime, LADA tends to experience rapid and progressive loss of beta cell function that requires intensive insulin therapy. This case report aims to describe a case of Diabetic Ketoacidosis (DKA) in a patient with latent autoimmune diabetes in adult (LADA) induced by sepsis (urinary tract infection/UTI). Case Presentations. A woman, 28 years-old, came to the Emergency Department (ED) RSMH Palembang with chief complaints of decreased consciousness and shortness of breath. Patient had a history of frequent urination, pain when urinating, and fever. Urinalysis examination were glycosuria, proteinuria, hematuria. Hb-A1c level was 10.7%, C-Peptide 0.11 ng/dL, Anti GAD65 qualitative positive, and Islet cell antibody (ICA) negative. Patient was diagnosed with diabetic ketoacidosis (DKA), LADA, and sepsis due to urinary tract infection (UTI). Patients were managed with DKA and sepsis management algorithm. Conclusion. Diabetic ketoacidosis (DKA) in LADA caused by sepsis is an emergency in the metabolic endocrine and diabetes fields. Prompt and appropriate management can improve outcome prognosis in this case.

Balanced Crystalloid Versus Normal Saline as Resuscitative Fluid in Diabetic Ketoacidosis

Background: Large volume resuscitation with normal saline (NS) may be associated with iatrogenic hyperchloremia and renal injury. Objective: The purpose of this study was to assess clinical outcomes associated with the use of Lactated Ringer’s (LR) compared to NS as resuscitative fluid in diabetic ketoacidosis (DKA). Methods: Single-center, retrospective analysis of patients admitted for DKA. The primary objective of this study was to evaluate the incidence of iatrogenic hyperchloremia associated with fluid resuscitation using balanced crystalloid compared to NS. Results Iatrogenic hyperchloremia occurred more frequently in the NS group compared to the LR group (74.4% vs 64.2%; P = 0.05). Mean maximum serum chloride was higher in the NS group (115.7 mmol/L vs 113.7 mmol/L; P = 0.004). Incidence of hypernatremia was higher in the NS group (18.3% vs 9.3%; P = 0.02). There was no significant difference in the incidence of AKI; however, mean change in serum creatinine at 48 hours showed a significantly greater decrease in the LR group (-0.15 mg/dL vs -0.04 mg/dL; P = 0.002). No significant differences were found in intensive care unit (ICU) length of stay or total hospital length of stay. Conclusion and Relevance This study found a statistically significant reduction in the incidence of iatrogenic hyperchloremia with the use of LR compared to NS as fluid resuscitation in DKA. Serum creatinine was more improved in the LR group versus NS group at 48 hours. Preferential use of balanced crystalloid for fluid resuscitation in DKA may reduce incidence of hyperchloremia and support renal recovery in this population.

Comparisons of biochemical parameters and diabetic ketoacidosis severity in adult patients with type 1 and type 2 diabetes

Objective The aim of this study was to determine the differences in biochemical parameters and diabetic ketoacidosis (DKA) severity in adult patients with type 1 and type 2 diabetes and utilization of serum BHB as a biomarker for DKA resolution was also evaluated. Materials and methods This prospective observational study of type 1 or type 2 diabetes mellitus who were diagnosed with DKA between 01 October 2018 and 30 September 2020. The correlations between serum BHB, measured by the Ranbut assay, and pH, bicarbonate, and anion gap were examined. Results A total of 99 diabetes patients were diagnosed with DKA (mean age 39.4 years, 63.4% female, 53.6% T2DM). while infection was the most common precipitating factor in T2DM (43.4%), non-compliance with treatment was the most common precipitating factor in T1DM (43.5%). T1DM patients had more severe DKA more hypokalemia during treatment. However, there was no significant difference in mortality between type1 and type2 diabetes. The initial laboratories evaluation of patients did not significant differ between type1 and type2 diabetes. Serum BHB during treatment of DKA was significantly correlated with changes in serum bicarbonate (r = − 0.64), serum anion gap (r = 0.84), and venous pH (r = − 0.6). The serum BHB levels corresponding to HCO3 levels for DKA severity were 4.5, 5.7, and 5.9 mmol/L in mild, moderate, and severe DKA, respectively. The serum BHB level of < 1 mmol/L had 73.7% sensitivity and 100% specificity to predict DKA resolution. Median time to resolution of DKA was 12 h with an optimized BHB cut-off value of < 1 mmol/L. There were no significant difference in time to resolution of DKA in the patients with type 1 and type 2 diabetes. Conclusions There are no differences in DKA-related biochemical parameters between type 1 and type 2 diabetes patients. The present findings suggest that DKA should be assessed and treated similarly, regardless of its occurrence in type 1 or type 2 diabetes patients.