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Huang S, Song F, Gao K, Song Y, Chen X. Plasma exchange treatment of a diabetic ketoacidosis child with hyperlipidemia to avoid pancreatitis: a case report. Front Pediatr 2024; 12:1280330. [PMID: 38903770 PMCID: PMC11188404 DOI: 10.3389/fped.2024.1280330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 05/14/2024] [Indexed: 06/22/2024] Open
Abstract
Type 1 diabetes mellitus (T1DM) is a metabolic disorder characterized by an absolute deficiency of insulin due to pancreatic failure. Diabetes ketoacidosis (DKA) has emerged as one of the most common complications of T1DM. Although exceedingly rare, the onset of T1DM with DKA may result in lipemia secondary to severe hypertriglyceridemia (HTG), accounting for several cases in the pediatric population. Along this line, plasma exchange treatment in children with DKA and severe hyperlipidemia has only been reported in some cases. In this case report, the diagnosis of an 11-year-old girl with diabetes ketoacidosis accompanied by severe HTG, along with subsequent plasma exchange treatment, is presented. Initially, the patient received initial management with crystalloid fluid bolus and intravenous insulin therapy. Despite rapid correction of acidosis, persistent HTG subsequently prompted the plasma exchange treatment. A total of three sessions were administered over 2 days, leading to a significant reduction in the triglyceride levels and corneal opacity resolution, indicating a successful therapeutic intervention.
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Affiliation(s)
| | | | | | | | - Xiaobo Chen
- Department of Endocrinology, The Children’s Hospital Affiliated to the Capital Institute of Pediatrics, Beijing, China
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Kravetz AM, Sanghavi P, Bhargava V, Shi RZ, Nally LM. Plasmapheresis as an Early Treatment for Severe Hypertriglyceridemia, Acute Pancreatitis, and Diabetic Ketoacidosis. AACE Clin Case Rep 2021; 7:315-319. [PMID: 34522772 PMCID: PMC8426612 DOI: 10.1016/j.aace.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/24/2021] [Indexed: 01/01/2023] Open
Abstract
Objective Severe hypertriglyceridemia (SHTG; plasma triglycerides >1000 mg/dL) is a rare but serious complication in children who develop diabetic ketoacidosis (DKA) from uncontrolled or new-onset type 1 diabetes. Methods We present the case of a severely malnourished 16-year-old with a 10-month history of presumed type 2 diabetes managed with lifestyle modifications and metformin, who presented with SHTG, acute pancreatitis, and DKA. On examination, there was no evidence of lipemia retinalis, cutaneous xanthomas, or xanthelasma. He was initially treated with an insulin infusion and intravenous fluids. Despite this treatment, his pancreatitis symptoms worseneed and lipase level increased, necessitating 2 courses of plasmapheresis that immediately resolved his symptoms and dramatically improved his clinical status. He was discharged on hospital day 5. During his hospital admission, islet cell antigen 512, insulin, glutamic acid decarboxylase 65, and zinc transporter 8 autoantibodies were positive in the presence of insulinopenia, consistent with type 1 diabetes. Results Hypertriglyceridemia and hypercholesterolemia did not recur during follow-up, suggesting that the underlying mechanism for SHTG was insulin deficiency. Conclusion This report of SHTG, DKA, and pancreatitis in an adolescent highlights the safe, early initiation of plasmapheresis as an effective treatment. To our knowledge, plasmapheresis has rarely been used so early in the course of treatment for an adolescent with SHTG, DKA, and acute pancreatitis.
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Affiliation(s)
- Ayesha Monga Kravetz
- Frank H. Netter MD School of Medicine, North Haven, Connecticut.,Department of Pediatrics, Division of Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Pooja Sanghavi
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Vidit Bhargava
- Department of Pediatrics, Division of Pediatric Intensive Care, Stanford University School of Medicine, Stanford, California
| | - Run Zhang Shi
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Laura Marie Nally
- Department of Pediatrics, Division of Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University School of Medicine, Stanford, California
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Mendelsohn RA, Taveras AN, Mazer BA, Clayton LM. Euglycemic Diabetic Ketoacidosis Precipitated by SGLT-2 Inhibitor Use, Pericarditis, and Fasting: A Case Report. Clin Pract Cases Emerg Med 2020; 4:389-392. [PMID: 32926693 PMCID: PMC7434240 DOI: 10.5811/cpcem.2020.4.46056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/03/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Less prevalent is euglycemic DKA (eDKA)-DKA with serum glucose less than 200 mg/dL; however, it is increasing in frequency with the introduction of sodium glucose cotransporter 2 (SGLT-2) inhibitors for treatment of type 2 diabetes. CASE REPORT We report a case of SGLT-2 inhibitor-associated eDKA presenting with concurrent acute pericarditis. DISCUSSION Our case suggests that the cause of eDKA can be multifactorial when decreased oral intake occurs in the setting of an acute cause of physiologic stress. CONCLUSION Prompt recognition of eDKA in the emergency department may allow earlier diagnosis and treatment directed at one or more of its underlying causes.
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Affiliation(s)
- Rebecca A Mendelsohn
- Florida Atlantic University Charles E. Schmidt College of Medicine, Department of Emergency Medicine, Boca Raton, Florida
| | - Anabelle N Taveras
- Florida Atlantic University Charles E. Schmidt College of Medicine, Department of Emergency Medicine, Boca Raton, Florida
| | - Benjamin A Mazer
- Florida Atlantic University Charles E. Schmidt College of Medicine, Department of Emergency Medicine, Boca Raton, Florida
| | - Lisa M Clayton
- Florida Atlantic University Charles E. Schmidt College of Medicine, Department of Emergency Medicine, Boca Raton, Florida
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Gajjar K, Luthra P. Euglycemic Diabetic Ketoacidosis in the Setting of SGLT2 Inhibitor Use and Hypertriglyceridemia: A Case Report and Review of Literature. Cureus 2019; 11:e4384. [PMID: 31218148 PMCID: PMC6553675 DOI: 10.7759/cureus.4384] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
We describe the case report of a patient with euglycemic diabetic ketoacidosis (euDKA), in the setting of sodium-glucose cotransporter-2 (SGLT2) inhibitor use, complicated by hypertriglyceridemia (HTG). A 28-year-old female with a history of gestational diabetes mellitus and subsequent type 2 diabetes mellitus (T2DM) on dapagliflozin and metformin presented with a one-week history of polyuria, poor appetite, and vomiting. On admission, serum glucose was 111 mg/dl, bicarbonate 18 mmol/l, anion gap 20, triglycerides 508 mg/dL, and venous pH 7.27. Serum ketone levels could not be assessed, as blood samples kept hemolyzing due to significant lipemia. The patient was initially admitted for starvation ketosis. However, serum chemistry obtained six hours after presentation revealed no change in the anion gap and a rise in triglycerides. She was treated with an insulin drip for euDKA and HTG with the resolution of the clinical picture. We performed a literature review of this topic and discuss the pathophysiology, diagnosis, management, and prevention of SGLT2-inhibitor-induced euDKA.
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Affiliation(s)
- Kushani Gajjar
- Internal Medicine, University of Connecticut Health Center, Farmington, USA
| | - Pooja Luthra
- Internal Medicine, University of Connecticut Health Center, Farmington, USA
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Fick T, Jack J, Pyle-Eilola AL, Henry RK. Severe hypertriglyceridemia at new onset type 1 diabetes mellitus. J Pediatr Endocrinol Metab 2017; 30:893-897. [PMID: 28742518 DOI: 10.1515/jpem-2017-0008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 06/12/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Severe hypertriglyceridemia (HTG) as well as diabetic ketoacidosis (DKA) are complications of type 1 diabetes (T1DM). HTG is an exceedingly rare complication in the pediatric population and herein we report a case of HTG at new-onset T1DM in DKA and discuss management and potential complications. CASE PRESENTATION An 11-year-old previously well patient with a history of fatigue and weight loss presented with: glucose >600 mg/dL, venous blood gas: pH 7.26, pCO2 20 mmHg, PO2 101 mmHg and base deficit 13 with triglyceride level 3573 mg/dL. An insulin drip was continued past criteria for discontinuation to facilitate lipoprotein lipase-based triglyceride metabolism. CONCLUSIONS Lipemia secondary to severe HTG, though exceedingly rare, may exist in new onset T1DM with DKA. Complicating the diagnosis is the possibility of an analytical error from lipemia causing incongruence in diagnostic criteria. Clinicians should rely on clinical criteria for management and should consider HTG if laboratory data is inconsistent with the clinical picture.
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Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism 2016; 65:507-21. [PMID: 26975543 DOI: 10.1016/j.metabol.2015.12.007] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/10/2015] [Accepted: 12/16/2015] [Indexed: 12/11/2022]
Abstract
The prognosis of diabetic ketoacidosis has undergone incredibly remarkable evolution since the discovery of insulin nearly a century ago. The incidence and economic burden of diabetic ketoacidosis have continued to rise but its mortality has decreased to less than 1% in good centers. Improved outcome is attributable to a better understanding of the pathophysiology of the disease and widespread application of treatment guidelines. In this review, we present the changes that have occurred over the years, highlighting the evidence behind the recommendations that have improved outcome. We begin with a discussion of the precipitants and pathogenesis of DKA as a prelude to understanding the rationale for the recommendations. A brief review of ketosis-prone type 2 diabetes, an update relating to the diagnosis of DKA and a future perspective are also provided.
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Affiliation(s)
- Ebenezer A Nyenwe
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 920 Madison Ave., Suite 300A, Memphis, TN 38163.
| | - Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 920 Madison Ave., Suite 300A, Memphis, TN 38163
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DKA with Severe Hypertriglyceridemia and Cerebral Edema in an Adolescent Boy: A Case Study and Review of the Literature. Case Rep Endocrinol 2016; 2016:7515721. [PMID: 26904318 PMCID: PMC4745619 DOI: 10.1155/2016/7515721] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/04/2016] [Indexed: 11/17/2022] Open
Abstract
A 13-year-old adolescent boy with type 1 diabetes mellitus (1b) presented with diabetic ketoacidosis (DKA) and cerebral edema. Grossly lipemic serum and lipemia retinals due to extremely high triglyceride (TG) level were observed without evidence of xanthoma or xanthelasma. Cerebral edema was treated by appropriate ventilation and mannitol administration. Normal saline was carefully given and regular insulin was titrated according to blood sugar levels. Triglyceride levels were reduced from 9,800 mg/dL to normal range within 9 days after conventional treatment was commenced without antilipid medication. Based on our review of the literature, this is the first reported case of confirmed pediatric DKA with severe hypertriglyceridemia and cerebral edema. In patients with DKA and hypertriglyceridemia, clinicians should be mindful of the possibility of associated acute pancreatitis and cerebral edema.
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Akinlade AT, Ogbera AO, Fasanmade OA, Olamoyegun MA. Serum C-peptide assay of patients with hyperglycemic emergencies at the Lagos State University Teaching Hospital (LASUTH), Ikeja. Int Arch Med 2014; 7:50. [PMID: 25945127 PMCID: PMC4413546 DOI: 10.1186/1755-7682-7-50] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 11/11/2014] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION HE are common acute complications of diabetes mellitus (DM) and include diabetic ketoacidosis (DKA), normo-osmolar hyperglycemic state (NHS) and hyperosmolar hyperglycemic state (HHS). They contribute a lot to the mortality and morbidity of DM. The clinical features include dehydration, hyperglycemia, altered mental status and ketosis. The basic mechanism of HE is a reduction in the net effective action of circulating insulin, resulting in hyperglycemia and ketonemia (in DKA) causing osmotic diuresis and electrolytes loss. Infection is a common precipitating factor. Measurement of serum C-peptide provides an accurate assessment of residual β-cell function and is a marker of insulin secretion in DM patients. AIM AND OBJECTIVES To assess the level of pancreatic beta cell function in HE patients, using the serum C-peptide. METHODOLOGY The biodata and clinical characteristics of the 99 subjects were collated using a questionnaire. All subjects had their serum C-peptide, glucose, electrolytes, urea, creatinine levels, urine ketones determined at admission. Results of statistical analysis were expressed as mean ± standard deviation (SD). A p value <0.05 was regarded statistically significant. Correlation between levels of serum C-peptide and admission blood glucose levels and the duration of DM respectively was done. RESULTS The mean age of the subjects was 51 (SD ± 16) years and comparable in both sexes. Mean duration of DM was 6.3 (SD ± 7.1) years, with 35% newly diagnosed at admission. The types of HE in this study are: DKA (24.7%), NHS (36.1%), and HHS (39.2%). Mean blood glucose in this study was 685 mg/dL, significantly highest in HHS and lowest in NHS. Mean serum C-peptide level was 1.6 ng/dL. It was 0.9 ng/dL in subjects with DKA and NHS while 2.7 ng/dL in HHS (p>0.05). Main precipitating factors were poor drug compliance, new-onset of DM and infection. CONCLUSION Most (70%) of subjects had poor pancreatic beta cell function, this may be a contributory factor to developing HE. Most subjects with high C-peptide levels had HHS.
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Akbay S, Yel A, Yıldırımer Ü, Can Ş, Dündar B. Diabetic ketoacidosis presenting with pseudonormoglycemia in a 15-year-old girl with type 1 diabetes mellitus. J Clin Res Pediatr Endocrinol 2013; 5:133-5. [PMID: 23748069 PMCID: PMC3701921 DOI: 10.4274/jcrpe.905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Pseudonormoglycemic diabetic ketoacidosis (DKA) is a rare condition and has been reported only in a few adult patients. We present a 15-year-old girl with a 9-year history of type 1 diabetes who presented with euglycemic and extreme hypertriglyceridemia. The acidosis and hypertriglyceridemia resolved with intravenous insulin therapy and rehydration. Hyperlipidemia was the apparent cause of pseudonormoglycemia in this patient. The findings in the present case demonstrate that also in children, DKA can rarely occur without abnormal blood glucose levels. Assessment of the acid-base status, urinary glucose, and ketone readings is therefore important in all diabetic patients who are unwell at admission and have normal glucose levels. In such patients, hyperlipidemia may cause pseudonormoglycemia. An awareness of this rare treatable life-threatening condition is important.
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Affiliation(s)
- Sinem Akbay
- İzmir Tepecik Training and Research Hospital, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Arda Yel
- İzmir Tepecik Training and Research Hospital, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Ülkü Yıldırımer
- İzmir Tepecik Training and Research Hospital, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Şule Can
- İzmir Tepecik Training and Research Hospital, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Bumin Dündar
- İzmir Katip Çelebi University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
,* Address for Correspondence: İzmir Katip Çelebi University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey Phone: +90 232 469 69 69 E-mail:
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Le Neveu F, Hywel B, Harvey JN. Euglycaemic ketoacidosis in patients with and without diabetes. PRACTICAL DIABETES 2013. [DOI: 10.1002/pdi.1769] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Affiliation(s)
- Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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McLean AG, Petersons CJ, Hooper AJ, Burnett JR, Burt MG, Doogue MP. Extreme diabetic lipaemia associated with a novel lipoprotein lipase gene mutation. Clin Chim Acta 2009; 406:167-9. [PMID: 19447100 DOI: 10.1016/j.cca.2009.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 05/01/2009] [Accepted: 05/01/2009] [Indexed: 02/01/2023]
Abstract
Diabetic lipaemia, severe hypertriglyceridaemia associated with diabetic ketoacidosis, is a well recognised, but rare condition. Why this occurs in some patients and not others is unknown. We report a case of extreme lipaemia in a 20-year-old woman with type 1 diabetes who presented to hospital with diabetic ketoacidosis (DKA). At admission the patient's blood was grossly lipaemic and plasma lipid analyses showed triglyceride and cholesterol concentrations of 379 mmol/L and 52 mmol/L, respectively. She had no peripheral stigmata of chronic hyperlipidaemia and 1 year previously her plasma triglyceride and total cholesterol concentrations were 2.5 mmol/L and 4.4 mmol/L respectively. She was treated with insulin and the hypertriglyceridaemia resolved over several days. Because of the marked hypertriglyceridaemia, lipoprotein lipase (LPL) genetic testing was performed. Sequencing of the LPL gene revealed that she was heterozygous for the common S447X LPL variant and heterozygous for a novel missense mutation in exon five (I225N). Ile(225) is highly conserved among species and this mutation is predicted to impair function of the mature LPL protein. We conclude that heterozygosity for LPL mutations may predispose to transient severe hypertriglyceridaemia, when combined with insulin deficiency.
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Affiliation(s)
- Anna G McLean
- Southern Adelaide Diabetes and Endocrine Services, Southern Adelaide Health Services, Adelaide, Australia.
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Kitabchi AE, Nyenwe EA. Hyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Endocrinol Metab Clin North Am 2006; 35:725-51, viii. [PMID: 17127143 DOI: 10.1016/j.ecl.2006.09.006] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) potentially are fatal but largely preventable acute metabolic conditions of uncontrolled diabetes, the incidence of which continues to increase. Mortality from DKA has declined remarkably over the years because of better understanding of its pathophysiology and treatment. The mortality rate of HHS remains alarmingly high, however, owing to older age and mode of presentation of patients and associated comorbid conditions. DKA and HHS also are economically burdensome; therefore, any resources invested in their prevention would be rewarding.
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Affiliation(s)
- Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2006; 29:2739-48. [PMID: 17130218 DOI: 10.2337/dc06-9916] [Citation(s) in RCA: 266] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 956 Court Ave., Suite D334, Memphis, Tennessee 38163, USA.
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Abstract
This article reviews the pathogenesis of diabetic ketoacidosis (DKA) and provides a rational approach to the management of patients with DKA. The therapeutic discussion includes the use of low-dose insulin, no bicarbonate, or phosphate therapy on the majority of DKA patients, based on numerous prospective randomized studies. The article also discusses controversial subjects such as the use of hypotonic versus isotonic saline with and without colloids, hydration of subjects before insulin therapy, and admission of DKA patients to the general ward versus emergency ward versus intensive care unit. A concise, simple protocol is also presented as a suitable reference for management of patients with DKA.
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Affiliation(s)
- A E Kitabchi
- Division of Endocrinology and Metabolism, University of Tennessee, Memphis
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Kaminska ES, Pourmotabbed G. Spurious laboratory values in diabetic ketoacidosis and hyperlipidemia. Am J Emerg Med 1993; 11:77-80. [PMID: 8447878 DOI: 10.1016/0735-6757(93)90066-k] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- E S Kaminska
- Department of Medicine, University of Tennessee, Memphis 38163
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