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Hyperglycaemic Crises and Lactic Acidosis in Diabetes Mellitus

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Hyperglycaemic Crises and Lactic Acidosis in Diabetes Mellitus 253 Postgrad Med J: first published as 10.1136/pgmj.2002.004291 on 11 May 2004. Downloaded from REVIEW Hyperglycaemic crises and lactic acidosis in diabetes mellitus P English, G Williams ............................................................................................................................... Postgrad Med J 2004;80:253–261. doi: 10.1136/pgmj.2002.004291 Diabetic ketoacidosis, hyperglycaemic hyperosmolar state, HHS replaces the older terms, ‘‘hyperglycaemic hyperosmolar non-ketotic coma’’ and ‘‘hypergly- and lactic acidosis represent three of the most serious acute caemic hyperosmolar non-ketotic state’’, because complications of diabetes. There have been some advances alterations of sensoria may be present without in our understanding of the pathogenesis of these coma, and mild to moderate ketosis is commonly present in this state.45 conditions over the last three decades, together with more Definitions vary according to the degree of uniform agreement on their treatment and innovations in hyperglycaemia and elevation of osmolality technology. Accordingly their incidence, morbidity, and required. Table 1 summarises the definition of Kitabchi et al.5 mortality are decreasing, but at rates that fall short of our aspirations. Hyperglycaemic crises in particular remain an Epidemiology important cause of morbidity and mortality in diabetic The annual incidence of DKA among subjects with type 1 diabetes is between 1% and 5% in populations around the world. In this article, understanding European and American series6–10 and this of these conditions and advances in their management, incidence appears to have remained relatively and the available guidelines for their treatment, are constant over the last decade in Western countries. Episodes of DKA are more common reviewed. As far as is possible, the recommendations are in younger than older subjects and are twice as based on clear published evidence; failing that, what is common in females than males.11 Mortality rates considered to be a common sense synthesis of consensus are reportedly less than 5% in experienced centres,5 10 12–15 but increase with age, approach- guidelines and recommendations is provided. ing 50% in those over the age of 80.11 ........................................................................... The incidence of HHS is more difficult to determine since there are few population based yperglycaemic crises are discussed together studies, and the frequent presence of complicat- followed by a separate section on lactic ing illnesses may lead to this diagnosis not being http://pmj.bmj.com/ acidosis. entered in discharge coding. HHS admission H rates appear to be lower than those for DKA and account for ,1% of admissions primarily DIABETIC KETOACIDOSIS (DKA) AND related to diabetes.16 17 Mortality rates are, how- HYPERGLYCAEMIC HYPEROSMOLAR ever, much higher at around 15%,14 16–19 perhaps STATE (HHS) reflecting the severity of the associated illnesses Definitions and the greater age of many of these patients. DKA has no universally agreed definition. Alberti on September 24, 2021 by guest. Protected copyright. proposed the working definition of ‘‘severe Precipitants uncontrolled diabetes requiring emergency treat- The commonest identified precipitant of DKA ment with insulin and intravenous fluids and and HHS is infection (see table 2), though the with a blood ketone body concentration of fact that DKA per se causes a raised white blood .5 mmol/l’’.1 Given the limited availability of cell count, vasodilatation, and polyuria may lead blood ketone body assays, a more pragmatic to over diagnosis of infection as a precipitant (see definition comprising a metabolic acidosis (pH box 2). The other principal precipitant is insulin ,7.3), plasma bicarbonate ,15 mmol/l, plasma See end of article for error, whether accidental or due to non-con- authors’ affiliations glucose .13.9 mmol/l, and urine ketostix reac- cordance, and failure to increase insulin during ....................... tion ++ or plasma ketostix > + may be more intercurrent illness. Other factors include myo- workable in clinical practice.2 Classifying the cardial infarction, stroke, new onset of type 1 Correspondence to: Dr Patrick English, severity of diabetic ketoacidosis is desirable, diabetes, pancreatitis, pulmonary embolism, Diabetes and since it may assist in determining the manage- excess alcohol ingestion, and drugs that alter Endocrinology Research ment and monitoring of the patient. Such a carbohydrate metabolism such as corticosteroids, Group, 3rd Floor Clinical classification is based on the severity of acidosis sympathomimetic agents, a-adrenergic and b- Sciences Centre, University Hospital Aintree, Lower (table 1). A caveat to this approach is that the adrenergic blockers, and diuretics. It is worth Lane, Liverpool L9 7AL, presence of an intercurrent illness, that may not noting that although DKA is most likely to occur UK; [email protected] necessarily affect the level of acidosis, may in individuals with type 1 diabetes, it is also well markedly affect outcome: a recent study showed described in individuals with type 2 diabetes and Submitted 12 September 2003 that the two most important factors predicting Accepted 1 October 2003 mortality in DKA were severe intercurrent illness Abbreviations: DKA, diabetic ketoacidosis; FFA, free ....................... and pH ,7.0.3 fatty acids; HHS, hyperglycaemic hyperosmolar state www.postgradmedj.com 254 English, Williams Postgrad Med J: first published as 10.1136/pgmj.2002.004291 on 11 May 2004. Downloaded from Table 1 Diagnostic criteria for diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) DKA Mild Moderate Severe HHS Plasma glucose (mmol/l >14 >14 >14 >30 Arterial pH 7.25–7.35 7.0–(7.24 ,7.0 .7.3 Serum bicarbonate (mmol/l) 15–18 10–14 ,10 .15 Urine ketones >++ >++ >++ (+ Plasma ketones >++ >++ >++ (+ Total osmolality (mOsm/kg)* Variable Variable Variable >340 Anion gapÀ .10 .12 .12 ,12 Level of consciousness Alert Alert/drowsy Stupor/coma Stupor/coma *Formula: 26{[Na+]+[K+]}+[urea]+[glucose]. + 2 2 5 ÀFormula: [Na ]–([Cl ]+[HCO3 ]) (mmol/l). Table largely adapted from Kitabchi et al. severe precipitating illness, who may be able to return to Hyperglycaemia therapy with oral hypoglycaemic agents once the acute illness Insulin deficiency and raised catecholamines, cortisol, and and hyperglycaemic crisis have been treated. DKA has also glucagon increase hepatic gluconeogenesis and enhance been increasingly described in obese African Americans with glycogenolysis. Hypercortisolaemia also increases protein type 2 diabetes, sometimes at diagnosis and sometimes after breakdown, providing increased amino acid precursors for relatively minor or undiagnosed precipitants in individuals gluconeogenesis. Glucose production is thus increased, while with reasonable baseline control.16 20 Characteristically these glucose disposal in peripheral tissues is decreased as a result individuals return to oral hypoglycaemic therapy or diet of both insulin deficiency and the insulin resistance induced control after resolution of the acute episode. by the raised levels of plasma catabolic hormones and free Recurrent episodes of DKA account for 15% of cases and fatty acids (FFA). Blood glucose levels rise, leading to are more common in those who are female, socially deprived, glycosuria, osmotic diuresis and dehydration, which and of lower educational status. Psychological problems decreases renal perfusion and renal glucose clearance complicated by eating disorder are associated with deliberate (especially in HHS), further exacerbating hyperglycaemia. omission or under-dosing with insulin and may contribute to 20% of these recurrent admissions in young type 1 diabetic Hyperketonaemia and acidosis patients.2 Hormone sensitive lipase mediates the breakdown of stored triglycerides in adipose tissue. It is exquisitely sensitive to Pathogenesis inhibition by insulin, while its activity is increased by the The primary mechanism for the development of ketoacidosis counter-regulatory hormones (especially catecholamines and and HHS is a reduction in the effective levels and/or action of cortisol). In DKA, profound insulin deficiency and elevated circulating insulin with a concomitant elevation of the levels of counter-regulatory hormones activate hormone counter-regulatory hormones: glucagon, catecholamines, sensitive lipase, increasing lipolysis and releasing large 21–24 cortisol, and growth hormone (fig 1), due to insulin amounts of glycerol and FFA into the portal circulation. http://pmj.bmj.com/ deficiency per se and intercurrent illness. Glycerol is a precursor for gluconeogenesis in both liver and kidneys while the hepatic mitochondria oxidise FFA to the ketone bodies acetoacetate and 3-hydroxybutyrate. Ketone Box 1: Useful equations bodies are strong organic acids and their rapid increase outstrips the bodies buffering capacity (provided by bicarbo- In DKA the accumulation of anionic ketones and the nate) leading to acidosis. consumption of bicarbonate as a buffer lead to an ‘‘anion Why ketoacidosis does not occur in HHS is unknown; on September 24, 2021 by guest. Protected copyright. gap’’ acidosis. The anion gap can be calculated by current theories draw attention to the lower levels of FFA and considering the usual major cations (K+ is not used because growth hormone, and the higher portal vein insulin 4 5 25–29 of its alterations in acid-base disturbances) and major anions concentrations. in plasma using the formula: + 2
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