Postgrad Med J: first published as 10.1136/pgmj.70.821.192 on 1 March 1994. Downloaded from Postgrad Med J (1994) 70, 192- 194 C) The Fellowship of Postgraduate Medicine, 1994 Acute renal failure in patients with type 1 diabetes mellitus G. Woodrow, A.M. Brownjohn and J.H. Turney Renal Unit, Leeds General Infirmary, Great George Street, Leeds LSJ 3EX, UK Summary: Acute renal failure (ARF) is a serious condition which still carries a mortality of around 50%. People with diabetes may be at increased risk of developing ARF, either as a complication of diabetic ketoacidosis or hyperosmolar coma, increased incidence of cardiovascular disease, or due to increased susceptibility ofthe kidney to adverse effects in the presence ofunderlying diabetic renal disease. During the period 1956-1992, 1,661 cases of ARF have been treated at Leeds General Infirmary. Of these, we have identified 26 patients also having type 1 diabetes. ARF due to diabetic ketoacidosis is surprisingly uncommon (14 cases out of 23 patients whose notes were reviewed). All cases of ARF complicating ketoacidosis in the last decade have been associated with particularly severe illness requiring intensive care unit support, rather than otherwise 'uncomplicated' ketoacidosis. We discuss the conditions that may result in ARF in patients with diabetes and the particular difficulties that may be encountered in management. Introduction People with diabetes may be at increased risk of Results developing acute renal failure (ARF). Acute pre- copyright. renal failure may occur as a result ofthe severe fluid Of 23 patients with type 1 diabetes complicated by depletion associated with diabetic ketoacidosis and ARF, diabetic ketoacidosis was the main underly- non-ketotic hyperosmolar coma. The presence of ing factor in 14 cases, non-ketotic hyperosmolar underlying diabetic nephropathy may predispose coma was present in one and the remaining eight to ARF resulting from adverse effects such as cases were due to causes other than acute metabolic hypotension, sepsis or exposure to nephrotoxic complications of diabetes. agents. The increased incidence of cardiovascular In the group ofpatients with ARF secondary to disease may also lead to renal impairment as a ketoacidosis there was a 50% mortality. Compared result of complications of ischaemic heart disease with the 10 earlier patients, the four patients http://pmj.bmj.com/ or renal artery atherosclerosis. We describe our treated since 1980 had more severe and compli- experience of treating patients with type 1 diabetes cated illnesses. All required mechanical ventilation, and ARF over the period 1956-1992 and discuss with three having hypotension unresponsive to the aetiology of renal failure and management of fluid replacement, requiring inotropic support. these patients. Cardiovascular depression would have been a major factor in the development of ARF in these patients. Two patients with ketoacidosis and ARF on September 26, 2021 by guest. Protected Methods died of severe metabolic derangement before dialysis could be instituted, two died from septi- Between 1956 and 1992 a total of 1,661 patients caemia, one from multiple organ failure, one from with ARF (sudden deterioration of renal function pulmonary aspiration and the other from non- to a creatinine of over 500 gmol/l or requiring recovery of renal function due to cortical necrosis. dialysis in patients without previously known The patient with non-ketotic hyperosmolar chronic renal impairment) were treated by the coma had not previously been diagnosed as Renal Unit at Leeds General Infirmary. We have diabetic. She was comatose on admission, with a identified 26 patients from Renal Unit records who blood glucose of 73.8 mmol/l, renal failure and also had type 1 diabetes mellitus without previous Gram-negative septicaemia of urinary tract origin. evidence of chronic renal impairment. We were After a complicated illness requiring ventilation able to obtain adequate records for 23 of these inotropic support for hypotension and dialysis, she patients for review of clinical details. died without recovery ofrenal or cerebral function. Eight patients had ARF not caused by acute Correspondence: G. Woodrow, M.R.C.P. disturbance of diabetic control. Three had severe Received: 15 September 1993 sepsis (renal abscess, empyema and biliary disease) Postgrad Med J: first published as 10.1136/pgmj.70.821.192 on 1 March 1994. Downloaded from RENAL FAILURE IN DIABETES MELLITUS 193 and all of these died. Three had cardiac causes of complicating urinary tract infection;6 and athero- ARF (myocardial infarction, cardiac failure and sclerotic renal artery disease complicated by either cardiac surgery) and only one ofthese survived. Of administration of angiotensin converting enzyme the remaining two patients, one had pre-renal ARF inhibitors or renal artery occlusion.7 One study has due to Addison's disease presenting as fluid deple- shown diabetes to increase the risk of ARF de- tion and uraemia, and the other occurred in a veloping from hypovolaemia,8 though two other patient with a fractured femur and pre-existing studies did not show diabetes to be an independent cardiac failure. Both ofthese recovered without the risk factor for development of ARF in patients need for dialysis. admitted to hospital or intensive care.9"0 It is important to remember that unexplained ARF in a patient with diabetes may be due to unrelated causes and exclusion ofurinary tract obstruction or Discussion intrinsic renal parenchymal disease is mandatory. The presence ofdiabetes poses certain particular Acute renal failure is a serious illness with a problems in the management of ARF. Prompt mortality still around 50% in most series.' Patients institution of dialysis is important as the diabetic with diabetes may be predisposed to the develop- patient may tolerate uraemia less well. Diabetes ment ofARF due to a variety ofreasons. Although must be well controlled as uncontrolled ketosis may diabetic ketoacidosis can result in severe fluid worsen hyperkalaemia and metabolic acidosis. depletion accompanied by marked metabolic dis- Insulin requirements are often altered, either being turbance, it is surprisingly rare for it to be compli- increased due to insulin resistance or decreased due cated by ARF. In a study of deaths in people with to impaired clearance of circulating insulin." diabetes under the age of 50 years, 74 out of 448 Although the majority of patients requiring deaths were due to ketoacidosis, yet only two of dialysis will receive intermittent haemodialysis, this these also developed ARF.2 It is our impression may be poorly tolerated in patients with cardiac that ARF due to 'uncomplicated' ketoacidosis may dysfunction or autonomic neuropathy, with be becoming even more rare, as our most recent development of hypotension during treatment. copyright. cases were complicated by cardiorespiratory Anticoagulation with heparin on dialysis may failure. The rarity of ARF complicating keto- increase the risk ofhaemorrhage from proliferative acidosis may reflect the standard of current man- retinopathy and prostacyclin may be used as a safer agement of this condition. It is also possible that alternative.'2 Although peritoneal dialysis causes the osmotic effect of hyperglycaemia tends to less cardiovascular disturbance, it may be com- preserve the intravascular volume and that the plicated by peritonitis and chest infections (due to associated diuresis protects against development of confinement in bed and splinting of the dia- ARF. phragm), and may provide inadequate control of http://pmj.bmj.com/ Non-ketotic hyperosmolar coma is charac- uraemia in the hypercatabolic patient. Continuous terized by profound dehydration and may be arteriovenous or venovenous haemofiltration (or accompanied by hypotension and uraemia. Presen- haemodialysis) are the best tolerated forms of tation is often late due to lack ofketotic symptoms treatment in patients with cardiovascular insta- and there are often associated problems such as bility, allowing greater fluid removal and so more neurological dysfunction and sepsis. Mortality is freedom for the administration of drugs and nutri- high with death often due to serious underlying tion. illness.3 Patients with diabetes may be at increased risk of on September 26, 2021 by guest. Protected Other causes of ARF which are more likely to developing ARF. This condition carries a high occur in patients with diabetes include radio- mortality and management may be more compli- contrast nephropathy, which is more likely to occur cated by the presence of diabetes. Some cases may in the presence ofdiabetic nephropathy,4 especially be avoidable by reducing exposure of the diabetic with chronic renal impairment;' papillary necrosis patient to nephrotoxic agents. References 1. Turney, J.H., Marshall, D.H., Brownjohn, A.M., Ellis, C.M. 4. Parfrey, P.S., Griffiths, S.M., Barrett, B.J. et al. Contrast & Parsons, F.M. The evolution of acute renal failure, material-induced renal failure in patients with diabetes mel- 1956-1988. Q J Med 1990, 74: 83-104. litus, renal insufficiency or both. N Engl J Med 1989, 320: 2. Tunbridge, W.M.G. Factors contributing to the deaths of 143-149. diabetics under fifty years of age. Lancet 1981, U: 569-572. 5. Weinrauch, L.A., Healey, R.W., Leland, O.S. et al. Coronary 3. McCurdy, D.K. Hyperosmolar hyperglycaemic nonketotic angiography and acute renal failure in diabetic azotaemic diabetic coma. Med Clin North Am 1970, 54: 683-699. nephropathy. Ann Intern Med 1977, 61: 56-69. Postgrad Med J: first published as 10.1136/pgmj.70.821.192 on 1 March 1994. Downloaded from 194 G. WOODROW et al. 6. Eknoyan, G., Qunibi, W.Y., Grissom, R.T., Tuma, S.M. & 10. Wilkins, R.G. & Faragher, E.B. Acute renal failure in an Ayus, J.C. Renal papillary necrosis: an update. Medicine intensive care unit: incidence, prediction and outcome. Anaes- 1982, 61: 55-73. thesia 1983, 38: 628-634. 7. Mohamed, A.S., Yaqoob, M. & Bell, G.M. Angiotensin- 11. Mak, R.H.K. & DeFronzo, R.A. Glucose and insulin converting enzyme inhibitors in diabetics with hypertension - metabolism, in uraemia.