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Challenges in Management of Diabetic Ketoacidosis in Hemodialysis Patients, Case Presentation and Review of Literature

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Challenges in Management of Diabetic Ketoacidosis in Hemodialysis Patients, Case Presentation and Review of Literature Diabetes & Metabolic Syndrome: Clinical Research & Reviews 13 (2019) 2481e2487 Contents lists available at ScienceDirect Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx Review Challenges in management of diabetic ketoacidosis in hemodialysis patients, case presentation and review of literature * Ayman Aly Seddik a, 1, Alaaeldin Bashier b, , 1, Amna Khalifa Alhadari a, Fakhryia AlAlawi a, Hind Hassan Alnour a, Azza Abdulaziz Bin Hussain b, Andrew Frankel c, Mohammed Jaffer Railey a a Nephrology Units, Dubai Hospital, Dubai Health Authority, United Arab Emirates b Endocrine Department, Dubai Hospital, Dubai Health Authority, United Arab Emirates c Imperial College Healthcare NHS Trust, UK article info abstract Article history: Chronic kidney disease is associated with accumulation of uremic toxins that increases insulin resistance Received 22 May 2019 which will lead to blunted ability to suppress hepatic gluconeogenesis and reduce peripheral utilization Accepted 27 June 2019 of insulin. CKD patients fail to increase insulin secretion in response to insulin resistance because of acidosis, 1,25 vitamin D deficiency, and secondary hyperparathyroidism. Hemodialysis causes further Keywords: fluctuations in glycemic control due to alterations in insulin secretion, clearance and resistance. DKA is Diabetes mellitus uncommon in hemodialysis patients because of the absence of glycosuria and osmotic diuresis which Diabetic ketoacidosis accounts for most of the fluid and electrolyte losses seen in DKA, anuric patients may be somewhat ESRD Hemodialysis protected from dehydration and shock, although still subject to hyperkalemia and metabolic acidosis. Hyperkalaemia However, substantial volume loss can still occur due to a prolonged decrease in oral intake or increased Hyperphosphatemia insensible water losses related to tachypnoea and fever. There is no current guidelines for the man- Hypomagnesemia agement of diabetic ketoacidosis in anuric hemodialysis patients considering their differences than Insulin therapy general population. In this review article we reviewed the literature and came with specific recom- mendations for management of Ketoacidosis in patients with CKD treated by hemodialysis. © 2019 Diabetes India. Published by Elsevier Ltd. All rights reserved. 1. Background to the metabolic complications of hyperglycaemia or ketoacidosis, but it is a consequence of the underlying precipitating illness [6,7]. Diabetes is leading cause of end-stage renal failure (ESRF) in Acute complications of diabetes such as Diabetic Ketoacidosis developed countries accounting for 40% of new ESRF cases in the (DKA) can be encountered in ESRF. DKA in ESRF presents a diag- USA and 25% of incident cases in the UK. The mortality rates for nostic and therapeutic challenge as illustrated by the five cases dialysis patients are high [1], with 10% first-year mortality rate for described in Supplement 1. The Japanese Society for Dialysis patients on maintenance hemodialysis (HD) reported in UK [2]. Therapy has also published a series of 14 case reports which These patients are at a particularly high-risk and the overall sur- describe the varying clinical presentation of DKA in ESRF [8] vival for patients with diabetes on maintenance HD is reported to (Table 1). The purpose of this paper is to provide recommendations be approximately halved compared to their non-diabetic peers (3.7 for the diagnosis and treatment of DKA in ESRF with particular vs. 7 years) [2]. In adult subjects with DKA (Diabetic Ketoacidosis), focus on areas where management differs from patients with the overall mortality is <1%; however, a mortality rate >5% has been preserved renal function. reported in the elderly and in patients with concomitant life- threatening illnesses [3e5]. In such situations, death is rarely due 2. Metabolic alterations In DKA, the effective insulin concentration is decreased while the concentration of counter-regulatory hormones (catechol- * Corresponding author. P.O. Box 94132, Dubai, United Arab Emirates. E-mail address: [email protected] (A. Bashier). amines, cortisol, glucagon and growth hormone) is increased 1 Joint first authors. resulting in hyperglycemia and ketosis. Hyperglycemia occurs due https://doi.org/10.1016/j.dsx.2019.06.022 1871-4021/© 2019 Diabetes India. Published by Elsevier Ltd. All rights reserved. 2482 A.A. Seddik et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 13 (2019) 2481e2487 Table 1 Case Reports published by The Japanese Soceity for Dialysis Therapy (Adapted from Ref. [8]). þ No. Age (yrs) Gender Type of DM Blood Glucose level (mg/dl) Arterial Blood pH Serum K level (mEq/L) 1 46 M 1 1467 7.09 6.6 2 63 F 1 1270 6.97 e 3 32 F 1 1912 6.76 7.2 465F e 609 7.15 e 536F ee e e 665M ee e e 7 71 F 2 1645 e 8.6 8 40s M 1 1365 7.10 8.5 9 35 M 1 1686 6.54 e 10 46 M 1 1520 7.10 7.5 11 58 M 1 1363 6.84 9.6 12 45 M 1 1360 ee 13 62 M 2 838 7.09 8.3 14 58 M e 1001 6.81 e Mean 52 1336 6.54 8.0 SD 13 369 0.20 1.0 SD e Standard Deviation, M e Male, F e Female, DM e Diabetes Mellitus. to increased gluconeogenesis, accelerated glycogenolysis, and [where Na is the serum sodium concentration, the multiple 2 ac- impaired glucose utilization by peripheral tissues [9e12]. This is counts for the osmotic contribution of the anions accompanying accompanied by transient insulin resistance. Insulin deficiency sodium (primarily chloride and bicarbonate), and 18 and 28 are combined with elevated counterregulatory hormones in DKA leads conversion factors from units of mg/dL into mmol/L respectively to the release of free fatty acids into the circulation from adipose [16e18]]. tissue (lipolysis) resulting in unrestrained hepatic fatty acid Interestingly, reports of DH and DKA are more frequently seen oxidation in the liver to ketone bodies (b-hydroxybutyrate and with patients on hemodialysis (HD) as compared to peritoneal acetoacetate) [13], leading to ketonemia and metabolic acidosis. dialysis (PD) [19e21]. No difference in serum sodium concentration In a state of preserved renal function, hyperglycemia-induced or tonicity was found between the two dialysis modalities for a osmotic diuresis can result in clinically significant extracellular comparable degree of hyperglycemia. volume deficits, dehydration and sodium depletion. The estimated The solute and fluid disturbances seen in patients with DH is fluid loss is nearly 6e10L with raised serum osmolality of different from the changes caused by hyperglycemia in patients 320e340mOsmol/L [14]. Hyperglycemia leads to a hypertonic state with preserved renal function as it is not complicated by osmotic in patients with preserved renal function as well as in patients on diuresis. The presence of hyperglycemia should lead to the devel- dialysis. In dialysis patients, diuresis is absent or minimal. However, opment of a hypertonic state in patients on dialysis and in those the accumulation of glucose in the extracellular space (EC) during with preserved renal function. However, DH results in extracellular development of hyperglycemia causes both hypertonicity and shifts volume expansion while severe hyperglycemia in preserved renal of intracellular fluid into the EC resulting in what is called dialysis function causes a clinically significant extracellular volume deficit. associated hyperglycemia (DH). In Dialysis associated hyperglyce- In DH baseline extracellular volume is theoretically an important mia (DH) and DKA or Hyperosmolar Hyperglycemic State (HHS) determinant of the degree of hypertonicity and extracellular vol- there is extracellular volume expansion resulting in edematous ume expansion in edematous patients is expected to result in patients having greater hypertonicity and extracellular hyper- greater hypertonicity and greater extracellular hypervolemia volemia than euvolemic or hypovolemic subjects with the same compared to euvolemic or hypovolemic subjects with the same degree of hyperglycemia [15,16]. degree of hyperglycemia. It is important to distinguish between tonicity and osmolality to understand the hyperglycemic changes in body fluids and solutes. 3. Diagnosis Osmolality and tonicity are related but not synonymous. Serum osmolality is the sum of all solutes in the serum (intracellular and Recommendation 1: DKA in patients with ESRD on HD is a rare extracellular), while tonicity (or effective osmolality) is the part of clinical presentation and difficult to diagnose. Since ESRD is a state total osmolality contributed by extracellular solutes having diffi- of persistent chronic metabolic acidosis, DKA should be suspected culty crossing cell membranes, therefore resulting in steady-state in patients with diabetes (specially type 1) who are unwell with an fluid shifts between extracellular compartment and intracellular acidosis that is greater than would normally be (persistent). In such compartment [15,16]. A high urea concentration is usually case measurement of Serum b-hydroxybutyrate is a useful tool in encountered in these situations, but it does not contribute to establishing diagnosis of DKA in patients with ESRD on HD. tonicity. Diagnostic criteria for DKA include presence of blood glucose The parameter of interest in DH patients and its management is >250 mg/dl, arterial pH of 7.30, bicarbonate level of 18 mEq/L, tonicity because it is the source of changes in cell volume and can and adjusted for albumin anion gap of >10e12 [22]. There is also an cause neurological manifestations in hyperglycemia [17]. Tonicity increase in the blood
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