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Morace C, Lorello G, Bellone F, Quartarone C, Ruggeri D, Giandalia A, Mandraffino G, Minutoli L, Squadrito G, Russo GT, Marini HR. Ketoacidosis and SGLT2 Inhibitors: A Narrative Review. Metabolites 2024; 14:264. [PMID: 38786741 PMCID: PMC11122992 DOI: 10.3390/metabo14050264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
An acute metabolic complication of diabetes mellitus, especially type 1, is diabetic ketoacidosis (DKA), which is due to an increase in blood ketone concentrations. Sodium/glucose co-transporter-2 inhibitor (SGLT2-i) drugs have been associated with the occurrence of a particular type of DKA defined as euglycemic (euDKA), characterized by glycemic levels below 300 mg/dL. A fair number of euDKA cases in SGLT2-i-treated patients have been described, especially in the last few years when there has been a significant increased use of these drugs. This form of euDKA is particularly insidious because of its latent onset, associated with unspecific symptomatology, until it evolves (progressing) to severe systemic forms. In addition, its atypical presentation can delay diagnosis and treatment. However, the risk of euDKA associated with SGLT2-i drugs remains relatively low, but it is essential to promptly diagnose and manage it to prevent its serious life-threatening complications. In this narrative review, we intended to gather current research evidence on SGLT2i-associated euDKA from randomized controlled trials and real-world evidence studies, its diagnostic criteria and precipitating factors.
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Affiliation(s)
- Carmela Morace
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Lipid Clinic and Cardiometabolic Disease Center, University Hospital of Messina, 98124 Messina, Italy
| | - Giuseppe Lorello
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Federica Bellone
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Lipid Clinic and Cardiometabolic Disease Center, University Hospital of Messina, 98124 Messina, Italy
| | - Cristina Quartarone
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Domenica Ruggeri
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Annalisa Giandalia
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
- Department of Human Pathology of Adulthood and Childhood “G. Barresi”, University of Messina, 98125 Messina, Italy
| | - Giuseppe Mandraffino
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Lipid Clinic and Cardiometabolic Disease Center, University Hospital of Messina, 98124 Messina, Italy
| | - Letteria Minutoli
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
| | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Giuseppina T. Russo
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
| | - Herbert Ryan Marini
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (C.M.); (F.B.); (G.M.); (L.M.); (G.S.); (G.T.R.)
- Internal Medicine and Diabetology Unit, University Hospital of Messina, 98124 Messina, Italy; (G.L.); (C.Q.); (D.R.); (A.G.)
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Meoli M, Lava SAG, Bronz G, Goeggel-Simonetti B, Simonetti GD, Alberti I, Agostoni C, Bianchetti MG, Scoglio M, Vismara SA, Milani GP. Eu- or hypoglycemic ketosis and ketoacidosis in children: a review. Pediatr Nephrol 2024; 39:1033-1040. [PMID: 37584686 PMCID: PMC10899420 DOI: 10.1007/s00467-023-06115-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/17/2023]
Abstract
The last decade has been characterized by exciting findings on eu- or hypoglycemic ketosis and ketoacidosis. This review emphasizes the following five key points: 1. Since the traditional nitroprusside-glycine dipstick test for urinary ketones is often falsely negative, the blood determination of β-hydroxybutyrate, the predominant ketone body, is currently advised for a comprehensive assessment of ketone body status; 2. Fasting and infections predispose to relevant ketosis and ketoacidosis especially in newborns, infants, children 7 years or less of age, and pregnant, parturient, or lactating women; 3. Several forms of carbohydrate restriction (typically less than 20% of the daily caloric intake) are employed to induce ketosis. These ketogenic diets have achieved great interest as antiepileptic treatment, in the management of excessive body weight, diabetes mellitus, and in sport training; 4. Intermittent fasting is more and more popular because it might benefit against cardiovascular diseases, cancers, neurologic disorders, and aging; 5. Gliflozins, a new group of oral antidiabetics inhibiting the renal sodium-glucose transporter 2, are an emerging cause of eu- or hypoglycemic ketosis and ketoacidosis. In conclusion, the role of ketone bodies is increasingly recognized in several clinical conditions. In the context of acid-base balance evaluation, it is advisable to routinely integrate both the assessment of lactic acid and β-hydroxybutyrate.
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Affiliation(s)
- Martina Meoli
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Gabriel Bronz
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Barbara Goeggel-Simonetti
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Giacomo D Simonetti
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Ilaria Alberti
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Agostoni
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Mario G Bianchetti
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland.
| | - Martin Scoglio
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
| | - Stefano A Vismara
- Family Medicine Institute, Università Della Svizzera Italiana, 6900, Lugano, Switzerland
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
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3
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Piel S, Janowska JI, Ward JL, McManus MJ, Aronowitz DI, Janowski PK, Starr J, Hook JN, Hefti MM, Clayman CL, Elmér E, Hansson MJ, Jang DH, Karlsson M, Ehinger JK, Kilbaugh TJ. Succinate prodrugs as treatment for acute metabolic crisis during fluoroacetate intoxication in the rat. Mol Cell Biochem 2023; 478:1231-1244. [PMID: 36282352 PMCID: PMC10540239 DOI: 10.1007/s11010-022-04589-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 10/12/2022] [Indexed: 10/31/2022]
Abstract
Sodium fluoroacetate (FA) is a metabolic poison that systemically inhibits the tricarboxylic acid (TCA) cycle, causing energy deficiency and ultimately multi-organ failure. It poses a significant threat to society because of its high toxicity, potential use as a chemical weapon and lack of effective antidotal therapy. In this study, we investigated cell-permeable succinate prodrugs as potential treatment for acute FA intoxication. We hypothesized that succinate prodrugs would bypass FA-induced mitochondrial dysfunction, provide metabolic support, and prevent metabolic crisis during acute FA intoxication. To test this hypothesis, rats were exposed to FA (0.75 mg/kg) and treated with the succinate prodrug candidate NV354. Treatment efficacy was evaluated based on cardiac and cerebral mitochondrial respiration, mitochondrial content, metabolic profiles and tissue pathology. In the heart, FA increased concentrations of the TCA metabolite citrate (+ 4.2-fold, p < 0.01) and lowered ATP levels (- 1.9-fold, p < 0.001), confirming the inhibition of the TCA cycle by FA. High-resolution respirometry of cardiac mitochondria further revealed an impairment of mitochondrial complex V (CV)-linked metabolism, as evident by a reduced phosphorylation system control ratio (- 41%, p < 0.05). The inhibition of CV-linked metabolism is a novel mechanism of FA cardiac toxicity, which has implications for drug development and which NV354 was unable to counteract at the given dose. In the brain, FA induced the accumulation of β-hydroxybutyrate (+ 1.4-fold, p < 0.05) and the reduction of mitochondrial complex I (CI)-linked oxidative phosphorylation (OXPHOSCI) (- 20%, p < 0.01), the latter of which was successfully alleviated by NV354. This promising effect of NV354 warrants further investigations to determine its potential neuroprotective effects.
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Affiliation(s)
- Sarah Piel
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA.
| | - Joanna I Janowska
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - J Laurenson Ward
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Meagan J McManus
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Danielle I Aronowitz
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Piotr K Janowski
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Jonathan Starr
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Jordan N Hook
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, USA
| | - Marco M Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, USA
| | - Carly L Clayman
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Eskil Elmér
- Abliva AB, Lund, Sweden
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Magnus J Hansson
- Abliva AB, Lund, Sweden
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - David H Jang
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pennsylvania School of Medicine, Philadelphia, USA
| | | | - Johannes K Ehinger
- Mitochondrial Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Otorhinolaryngology, Head and Neck Surgery, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Todd J Kilbaugh
- Resuscitation Science Center of Emphasis, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
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Polachini GM, de Castro TB, Smarra LFS, Henrique T, de Paula CHD, Severino P, López RVM, Carvalho AL, de Mattos Zeri AC, Silva IDCG, Tajara EH. Plasma metabolomics of oral squamous cell carcinomas based on NMR and MS approaches provides biomarker identification and survival prediction. Sci Rep 2023; 13:8588. [PMID: 37237049 DOI: 10.1038/s41598-023-34808-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Metabolomics has proven to be an important omics approach to understand the molecular pathways underlying the tumour phenotype and to identify new clinically useful markers. The literature on cancer has illustrated the potential of this approach as a diagnostic and prognostic tool. The present study aimed to analyse the plasma metabolic profile of patients with oral squamous cell carcinoma (OSCC) and controls and to compare patients with metastatic and primary tumours at different stages and subsites using nuclear magnetic resonance and mass spectrometry. To our knowledge, this is the only report that compared patients at different stages and subsites and replicates collected in diverse institutions at different times using these methodologies. Our results showed a plasma metabolic OSCC profile suggestive of abnormal ketogenesis, lipogenesis and energy metabolism, which is already present in early phases but is more evident in advanced stages of the disease. Reduced levels of several metabolites were also associated with an unfavorable prognosis. The observed metabolomic alterations may contribute to inflammation, immune response inhibition and tumour growth, and may be explained by four nonexclusive views-differential synthesis, uptake, release, and degradation of metabolites. The interpretation that assimilates these views is the cross talk between neoplastic and normal cells in the tumour microenvironment or in more distant anatomical sites, connected by biofluids, signalling molecules and vesicles. Additional population samples to evaluate the details of these molecular processes may lead to the discovery of new biomarkers and novel strategies for OSCC prevention and treatment.
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Affiliation(s)
- Giovana Mussi Polachini
- Department of Molecular Biology, School of Medicine of São José Do Rio Preto - FAMERP, Av. Brigadeiro Faria Lima, 5416, Vila São Pedro, São José do Rio Preto, SP, CEP 15090-000, Brazil
| | - Tialfi Bergamin de Castro
- Department of Molecular Biology, School of Medicine of São José Do Rio Preto - FAMERP, Av. Brigadeiro Faria Lima, 5416, Vila São Pedro, São José do Rio Preto, SP, CEP 15090-000, Brazil
| | - Luis Fabiano Soares Smarra
- Department of Molecular Biology, School of Medicine of São José Do Rio Preto - FAMERP, Av. Brigadeiro Faria Lima, 5416, Vila São Pedro, São José do Rio Preto, SP, CEP 15090-000, Brazil
- Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of São Paulo, São Paulo, SP, Brazil
| | - Tiago Henrique
- Department of Molecular Biology, School of Medicine of São José Do Rio Preto - FAMERP, Av. Brigadeiro Faria Lima, 5416, Vila São Pedro, São José do Rio Preto, SP, CEP 15090-000, Brazil
| | - Carlos Henrique Diniz de Paula
- Department of Molecular Biology, School of Medicine of São José Do Rio Preto - FAMERP, Av. Brigadeiro Faria Lima, 5416, Vila São Pedro, São José do Rio Preto, SP, CEP 15090-000, Brazil
| | - Patricia Severino
- Albert Einstein Research and Education Institute, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | - André Lopes Carvalho
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, SP, Brazil
| | | | | | - Eloiza H Tajara
- Department of Molecular Biology, School of Medicine of São José Do Rio Preto - FAMERP, Av. Brigadeiro Faria Lima, 5416, Vila São Pedro, São José do Rio Preto, SP, CEP 15090-000, Brazil.
- Department of Genetics and Evolutionary Biology, Institute of Biosciences, University of São Paulo, São Paulo, SP, Brazil.
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5
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Examination of Postmortem β-Hydroxybutyrate Increase in Forensic Autopsy Cases. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12147181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Ketoacidosis is one of the common diseases that sometimes result in death. In forensic autopsy cases, the measuring of ketone bodies, especially β-hydroxybutyrate (BHB), is useful in diagnosing postmortem ketoacidosis as a cause of death. However, increased BHB values are not always indicative of ketoacidosis. Other causes of death, such as hypothermia, are known to increase BHB values. In addition, sometimes, we experience cases of increased BHB values that are unlikely to be associated with the pathophysiology or the cause of death resulting in an increase in BHB values. In this study, autopsies were performed to determine the relationship between blood BHB values and the postmortem interval (PMI). The patients were divided into four groups: PMI ≤ 24 h, PMI ≤ 48 h, PMI ≤ 72 h, and PMI > 72 h. The BHB values for each group were then compared. Based on the analysis, patients with a PMI ≤ 72 h and those with a PMI > 72 h had significantly higher BHB values than patients with a PMI ≤ 24 h. In conclusion, there remains a possibility that the BHB values increase after death. Forensic pathologists should consider PMI when diagnosing ketoacidosis as the cause of death.
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Anderson JC, Mattar SG, Greenway FL, Lindquist RJ. Measuring ketone bodies for the monitoring of pathologic and therapeutic ketosis. Obes Sci Pract 2021; 7:646-656. [PMID: 34631141 PMCID: PMC8488448 DOI: 10.1002/osp4.516] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/29/2021] [Accepted: 04/11/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The ketone bodies β-hydroxybutyrate (BOHB) and acetone are generated as a byproduct of the fat metabolism process. In healthy individuals, ketone body levels are ∼0.1 mM for BOHB and ∼1 part per million for breath acetone (BrAce). These levels can increase dramatically as a consequence of a disease process or when used therapeutically for disease treatment. For example, increased ketone body concentration during weight loss is an indication of elevated fat metabolism. Ketone body measurement is relatively inexpensive and can provide metabolic insights to help guide disease management and optimize weight loss. METHODS This review of the literature provides metabolic mechanisms and typical concentration ranges of ketone bodies, which can give new insights into these conditions and rationale for measuring ketone bodies. RESULTS Diseases such as heart failure and ketoacidosis can affect caloric intake and macronutrient management, which can elevate BOHB 30-fold and BrAce 1000-fold. Other diseases associated with obesity, such as brain dysfunction, cancer, and diabetes, may cause dysfunction because of an inability to use glucose, excessive reliance on glucose, or poor insulin signaling. Elevating ketone body concentrations (e.g., nutritional ketosis) may improve these conditions by forcing utilization of ketone bodies, in place of glucose, for fuel. During weight loss, monitoring ketone body concentration can demonstrate program compliance and can be used to optimize the weight-loss plan. CONCLUSIONS The role of ketone bodies in states of pathologic and therapeutic ketosis indicates that accurate measurement and monitoring of BOHB or BrAce will likely improve disease management. Bariatric surgery is examined as a case study for monitoring both types of ketosis.
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Affiliation(s)
- Joseph C. Anderson
- Department of BioengineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Samer G. Mattar
- Department of SurgeryBaylor College of MedicineHoustonTexasUSA
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Abdelkreem E, Magdy RM, Sadek AA. Characterization and outcome of 11 children with non-diabetic ketoacidosis. J Pediatr Endocrinol Metab 2021; 34:95-102. [PMID: 33581701 DOI: 10.1515/jpem-2020-0324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/03/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To study the clinical and laboratory features, management, and outcome of pediatric non-diabetic ketoacidosis (NDKA). METHODS Between May 2018 and April 2020, we prospectively collected children under 18 years who presented with ketoacidosis, defined as ketosis (urinary ketones ≥++ and/or serum β-hydroxybutyrate level ≥3 mmol/L) and metabolic acidosis (pH <7.3 and HCO3 - <15 mmol/L). Children with HbA1c level ≥6.5% at initial presentation and those meeting the diagnostic criteria for DM during follow-up were excluded. Data were collected on demographics, clinical and laboratory features, management, and outcome. RESULTS Eleven children with 19 episodes of NDKA were identified. The median age was 12 months (range from 5 months to 5 years). They manifested dehydration and disturbed conscious level (all cases), convulsions (n=6), hypoglycemia (n=6), hyperglycemia (n=2) and significant hyperammonemia (n=4). Most cases required intensive care management. Death or neurodevelopmental impairment occurred in six cases. Seven cases had inborn errors of metabolism (IEMs). Other cases were attributed to starvation, sepsis, and salicylate intoxication. CONCLUSIONS This is the largest case series of pediatric NDKA. Ketoacidosis, even with hyperglycemia, is not always secondary to diabetes mellitus. IEMs may constitute a significant portion of pediatric NDKA. Increased awareness of this unfamiliar condition is important for prompt diagnosis, timely management, and better outcome.
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Affiliation(s)
- Elsayed Abdelkreem
- Department of Pediatrics, Faculty of Medicine, Sohag University, Sohag 82524, Egypt
| | - Rofaida M Magdy
- Department of Pediatrics, Faculty of Medicine, Sohag University, Sohag 82524, Egypt
| | - Abdelrahim A Sadek
- Department of Pediatrics, Faculty of Medicine, Sohag University, Sohag 82524, Egypt
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8
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Eriksson Hydara Y, Zilg B. Postmortem diagnosis of ketoacidosis: Levels of beta-hydroxybutyrate, acetone and isopropanol in different causes of death. Forensic Sci Int 2020; 314:110418. [DOI: 10.1016/j.forsciint.2020.110418] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/16/2022]
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Marzban S, Arbee M, Vorajee N, Richards GA. Non-diabetic ketoacidosis associated with a low carbohydrate, high fat diet in a postpartum lactating female. Oxf Med Case Reports 2020; 2020:omz026. [PMID: 32793371 PMCID: PMC7416821 DOI: 10.1093/omcr/omz026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/21/2019] [Accepted: 03/02/2019] [Indexed: 12/18/2022] Open
Abstract
A 31-year old non-diabetic woman presented to our hospital with symptoms of dehydration, drowsiness, fatigue, shortness of breath and vomiting present for two consecutive days prior to admission. She had started a low carbohydrate, high fat (LCHF) diet to induce weight loss while breastfeeding her 4-month-old child 2 weeks prior to admission. The patient was found to have a severely high anion gap metabolic acidosis. It was determined to be due to ketoacidosis, which was as a result of carbohydrate restriction in the presence of increased metabolic demands related with the synthesis and secretion of milk. She denied alcohol use or ingestion of any drugs prior to admission. The patient underwent dialysis and received insulin, 5% dextrose water alongside a well-balanced diet with adequate calories. All abnormal laboratory results normalized and follow-up visits were done. Lactating women are at risk of developing ketoacidosis due to high metabolic demands of the body to produce milk. LCHF diets may exacerbate the body's demand to meet its milk production requirement and result in ketoacidosis. Health professionals need to be aware of the complications of LCHF diet in this population to prevent mortality associated with this condition.
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Affiliation(s)
- Saba Marzban
- Clinical Pharmacy, Netcare Christiaan Barnard Memorial Hospital, Cape Town, South Africa
| | - Mohamed Arbee
- Clinical Haematology, Netcare Garden City Hospital, Johannesburg, Gauteng, South Africa
| | - Naseema Vorajee
- Division of Pathology, National Institute for Occupational Health, National Health Laboratory Services, Johannesburg, Gauteng, South Africa
| | - Guy A Richards
- Division of Critical Care Charlotte Maxeke Hospital and University of the Witwatersrand, Faculty of Health Sciences
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10
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Sinha S, Gavaghan D, Yew S. Euglycaemic ketoacidosis from an
SGLT
2 inhibitor exacerbated by a ketogenic diet. Med J Aust 2019; 212:46-46.e1. [DOI: 10.5694/mja2.50434] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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11
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Millar R, Harding A. Review article: Accelerated starvation of childhood: Have I judged ketones? Emerg Med Australas 2019; 31:314-320. [PMID: 30916481 DOI: 10.1111/1742-6723.13276] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 02/14/2019] [Accepted: 02/17/2019] [Indexed: 12/19/2022]
Abstract
Acute ketosis is an important physiological mechanism to prevent irreversible neurological damage from hypoglycaemia during starvation, and represents a significant metabolic stress. A cohort of children adapt to relatively short periods of reduced caloric intake by generating large quantities of ketone bodies. When excessive, the gastrointestinal symptoms of starvation ketosis such as nausea and pain may create a vicious cycle that delays spontaneous resolution. The presence of ketones can be dismissed as a normal feature of childhood metabolism, sometimes even when extreme. A broader understanding of this process under the banner of 'accelerated starvation of childhood' is helpful for clinicians managing acute illness in children. We advocate that children less than 7 years of age with a history suggestive of accelerated starvation of childhood should be screened by emergency clinicians for ketosis using a simple and cheap bedside capillary test, even if glucose levels are greater than 2.6 mmol/L. Identification and appropriate management of ketosis may alleviate the distressing gastrointestinal symptoms associated with many minor illnesses, and potentially prevent hypoglycaemia in some children. Appropriate advice to carers may be helpful to prevent further episodes. Illustrative case examples from our own practice are provided.
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Affiliation(s)
- Robert Millar
- The University of Melbourne, Melbourne, Victoria, Australia.,Austin Hospital, Melbourne, Victoria, Australia.,Epworth Hospital, Melbourne, Victoria, Australia
| | - Anton Harding
- The University of Melbourne, Melbourne, Victoria, Australia.,Austin Hospital, Melbourne, Victoria, Australia.,Epworth Hospital, Melbourne, Victoria, Australia.,Royal Children's Hospital, Melbourne, Victoria, Australia
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Vanmassenhove J, Lameire N. Approach to the patient presenting with metabolic acidosis. Acta Clin Belg 2019; 74:21-27. [PMID: 30472928 DOI: 10.1080/17843286.2018.1547245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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13
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Griebsch C, Whitney J, Angles J, Bennett P. Acute liver failure in two dogs following ingestion of cheese tree (Glochidion ferdinandi) roots. J Vet Emerg Crit Care (San Antonio) 2018; 29:190-200. [PMID: 30507024 DOI: 10.1111/vec.12790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 10/15/2017] [Accepted: 11/07/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To describe the management and resolution of acute liver failure (ALF) in two dogs following ingestion of cheese tree (Glochidion ferdinandi) roots. CASE SUMMARIES A 2-year-old male entire Bullmastiff and a 5-year-old female neutered German Shepherd dog were presented for acute-onset lethargy and vomiting after chewing on tree roots of a cheese tree. Both dogs developed clinical abnormalities consistent with ALF, including hepatic encephalopathy, marked increase in alanine aminotransferase activity and bilirubin concentration, and prolonged coagulation times. Treatment included administration of intravenous fluids, hepatoprotectants, vitamin K1 , antibiotics, lactulose, antacids, antiemetics, and multiple fresh frozen plasma transfusions. Follow-up examinations performed 30 days after initial presentation revealed the dogs to be clinically healthy with serum biochemical and coagulation profiles within reference intervals. NEW OR UNIQUE INFORMATION This is the first report describing ALF in two dogs following ingestion of cheese tree (G. ferdinandi) roots. In this clinical setting, despite a poor prognosis, survival and recovery of adequate liver function were possible with medical management.
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Affiliation(s)
| | - Joanna Whitney
- University Veterinary Teaching Hospital, Sydney, Australia
| | - John Angles
- Animal Referral Hospital, Homebush, Australia
| | - Peter Bennett
- University Veterinary Teaching Hospital, Sydney, Australia
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Pfob CH, Eiber M, Luppa P, Maurer F, Maurer T, Tauber R, D'Alessandria C, Feuerecker B, Scheidhauer K, Ott A, Heemann U, Schwaiger M, Schmaderer C. Hyperkalemia in patients treated with endoradiotherapy combined with amino acid infusion is associated with severe metabolic acidosis. EJNMMI Res 2018; 8:17. [PMID: 29488080 PMCID: PMC5829280 DOI: 10.1186/s13550-018-0370-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/19/2018] [Indexed: 01/08/2023] Open
Abstract
Background Amino acid co-infusion for renal protection in endoradiotherapy (ERT) applied as prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (RLT) or peptide receptor radionuclide therapy (PRRT) has been shown to cause severe hyperkalemia. The pathophysiology behind the rapid development of hyperkalemia is not well understood. We hypothesized that the hyperkalemia should be associated with metabolic acidosis. Results Twenty-two patients underwent ERT. Prior to the first cycle, excretory kidney function was assessed by mercapto-acetyltriglycine (MAG-3) renal scintigraphy, serum biochemistry, and calculated glomerular filtration rate (eGFR). All patients received co-infusion of the cationic amino acids L-arginine and L-lysine for nephroprotection. Clinical symptoms, electrolytes, and acid-base status were evaluated at baseline and after 4 h. No patient developed any clinically relevant side effects. At baseline, acid base status and electrolytes were normal in all patients. Excretory kidney function was normal or only mildly impaired in all except two patients with stage 3 renal insufficiency. All patients developed hyperkalemia. Base excess and HCO3− were significantly lower after 4 h. In parallel, mean pH dropped from 7.36 to 7.29. There was a weak association between calculated (r = − 0.21) as well as MAG-3-derived GFR (r = − 0.32) and the rise in potassium after 4 h. Conclusion Amino acid co-infusion during ERT leads to severe metabolic acidosis which induces hyperkalemia by potassium hydrogen exchange. This novel finding implies that commercially available bicarbonate solutions might be an easy therapeutic option to correct metabolic acidosis rapidly. Electronic supplementary material The online version of this article (10.1186/s13550-018-0370-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian H Pfob
- Department of Nuclear Medicine, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Peter Luppa
- Department of Pathobiochemistry, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Florian Maurer
- Hospital Pharmacy Department, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Tobias Maurer
- Department of Urology, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Robert Tauber
- Department of Urology, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Calogero D'Alessandria
- Department of Nuclear Medicine, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Benedikt Feuerecker
- Department of Nuclear Medicine, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Klemens Scheidhauer
- Department of Nuclear Medicine, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Armin Ott
- Institute of Medical Statistics and Epidemiology, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Markus Schwaiger
- Department of Nuclear Medicine, Technische Universität München, Klinikum rechts der Isar, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Technische Universität München, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
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Effects of feeding drunken horse grass infected with Epichloë gansuensis endophyte on animal performance, clinical symptoms and physiological parameters in sheep. BMC Vet Res 2017; 13:223. [PMID: 28724414 PMCID: PMC5518123 DOI: 10.1186/s12917-017-1120-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 06/19/2017] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Many reports showed that grass-endophyte symbiosis induced livestock poisoned. Yet, there is no study evaluating clinical symptoms and physiological parameters in sheep fed Epichloë gansuensis endophyte-infected grass. The objective of the present study was to investigate these indexes by feeding sheep with endophyte-infected A. inebrians (E+ Group) or endophyte-free A. inebrians (E- Group) drunken horse grass or alfalfa hay (Control Group). RESULTS The Epichloë endophyte caused obvious toxicity symptoms in the sheep fed E+ A. inebrians, with 1 of the 5 sheep having died by the 35th day. The feed intake and body weight gain of the E+ Group were significantly less than the E- and control groups (P < 0.05). Serum concentrations of alanine aminotransferase (ALT, 45.5 mmol/L) and aspartate aminotransferase for the E+ group (AST, 139.3 mmol/L) were significantly (P < 0.05) greater than for the E- (ALT, 31.2 mmol/L; AST, 78.6 mmol/L) and control (ALT, 32.6 mmol/L; AST, 56.6 mmol/L) groups at the fifth week; serum concentration of creatinine for the E+ group (63.8 mmol/L) was also significantly (P < 0.05) greater than for E- (56.6 mmol/L) and control groups (58.5 mmol/L). Meanwhile, urine biochemical indices for the E+ group indicated that ketone and occult blood were significantly (P < 0.05) elevated compared to the other groups while urine pH values were significantly (P < 0.05) acidic. The relative weight of heart, brain, liver, lung and kidney for Group E+ were almost two fold more than the other groups, but uterus weight was about half that found for Group E- or Control. CONCLUSIONS We conclude that the Epichloë endophyte infection is the cause of A. inebrians toxicity to sheep. Interestingly, none of the measured parameters differed significantly between E- and the control groups, which implied that drunken horse grass could be utilized efficiently by sheep when not infected by the Epichloë endophyte.
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Handelsman Y, Henry RR, Bloomgarden ZT, Dagogo-Jack S, DeFronzo RA, Einhorn D, Ferrannini E, Fonseca VA, Garber AJ, Grunberger G, LeRoith D, Umpierrez GE, Weir MR. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT ON THE ASSOCIATION OF SGLT-2 INHIBITORS AND DIABETIC KETOACIDOSIS. Endocr Pract 2016; 22:753-62. [PMID: 27082665 DOI: 10.4158/ep161292.ps] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
ABBREVIATIONS AACE = American Association of Clinical Endocrinologists ACE = American College of Endocrinology DKA = diabetic ketoacidosis EMA = European Medicines Agency FDA = U.S. Food and Drug Administration SGLT-2 = sodium glucosecotransporter 2 T1D = type 1 diabetes T2D = type 2 diabetes.
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Akgul Kalkan E, Sahiner M, Ulker Cakir D, Alpaslan D, Yilmaz S. Quantitative Clinical Diagnostic Analysis of Acetone in Human Blood by HPLC: A Metabolomic Search for Acetone as Indicator. JOURNAL OF ANALYTICAL METHODS IN CHEMISTRY 2016; 2016:5176320. [PMID: 27298750 PMCID: PMC4889849 DOI: 10.1155/2016/5176320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/26/2016] [Accepted: 05/04/2016] [Indexed: 06/06/2023]
Abstract
Using high-performance liquid chromatography (HPLC) and 2,4-dinitrophenylhydrazine (2,4-DNPH) as a derivatizing reagent, an analytical method was developed for the quantitative determination of acetone in human blood. The determination was carried out at 365 nm using an ultraviolet-visible (UV-Vis) diode array detector (DAD). For acetone as its 2,4-dinitrophenylhydrazone derivative, a good separation was achieved with a ThermoAcclaim C18 column (15 cm × 4.6 mm × 3 μm) at retention time (t R) 12.10 min and flowrate of 1 mL min(-1) using a (methanol/acetonitrile) water elution gradient. The methodology is simple, rapid, sensitive, and of low cost, exhibits good reproducibility, and allows the analysis of acetone in biological fluids. A calibration curve was obtained for acetone using its standard solutions in acetonitrile. Quantitative analysis of acetone in human blood was successfully carried out using this calibration graph. The applied method was validated in parameters of linearity, limit of detection and quantification, accuracy, and precision. We also present acetone as a useful tool for the HPLC-based metabolomic investigation of endogenous metabolism and quantitative clinical diagnostic analysis.
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Affiliation(s)
- Esin Akgul Kalkan
- Department of Forensic Medicine, Faculty of Medicine, Canakkale Onsekiz Mart University, Terzioglu Campus, 17020 Canakkale, Turkey
| | - Mehtap Sahiner
- Department of Leather Engineering, Faculty of Engineering, Ege University, Bornova, 35100 İzmir, Turkey
| | - Dilek Ulker Cakir
- Department of Clinical Biochemistry, Faculty of Medicine, Canakkale Onsekiz Mart University, Terzioglu Campus, 17020 Canakkale, Turkey
| | - Duygu Alpaslan
- Department of Chemical Engineering, Faculty of Engineering, Yuzuncu Yil University, 65080 Van, Turkey
| | - Selehattin Yilmaz
- Department of Chemistry, Faculty of Sciences and Arts, Canakkale Onsekiz Mart University, Terzioglu Campus, 17020 Canakkale, Turkey
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Hurrell FE, Drobatz KJ, Hess RS. Beta-hydroxybutyrate Concentrations in Dogs with Acute Pancreatitis and Without Diabetes Mellitus. J Vet Intern Med 2016; 30:751-5. [PMID: 27075106 PMCID: PMC4913575 DOI: 10.1111/jvim.13947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/12/2016] [Accepted: 03/17/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND β-hydroxybutyrate (BOHB) concentrations have not been quantified in dogs with acute pancreatitis (AP). OBJECTIVE The aim of this study was to investigate BOHB concentrations in dogs with AP. ANIMALS A total of 154 client-owned dogs without DM. METHODS Prospective clinical study. Dogs were enrolled into 1 of 3 groups: AP, sick without an AP diagnosis, or fasted. Dogs were diagnosed with AP (44) if they had vomiting or anorexia, and either ultrasonographic findings consistent with AP or increased pancreatic lipase. Sick dogs without AP (68) had vomiting or anorexia but a diagnosis of AP was either not suspected or was excluded based on ultrasonographic findings or a normal pancreatic lipase. Dogs without anorexia or vomiting that were fasted for over 10 hours for a procedure were also enrolled (42). BOHB was measured on whole blood with a portable ketone meter. The Kruskal-Wallis test was performed to compare BOHB in the 3 groups. Pair-wise comparisons were performed using the Mann-Whitney test and Bonferroni corrected P-values are reported. RESULTS Median BOHB concentration was significantly higher in dogs with AP (0.3 mmol/L, range 0-2.9 mmol/L) compared to sick dogs without AP (0.20 mmol/L, range 0-0.9 mmol/L, P = .007) and fasted dogs (0.1 mmol/L, range 0-0.4 mmol/L, P = .0001). Median BOHB concentration was significantly higher in sick dogs without AP compared to fasted dogs (P = .0002). CONCLUSIONS AND CLINICAL IMPORTANCE In dogs without DM, BOHB is significantly higher in dogs with AP compared to other dogs. The diagnostic utility of this finding remains to be investigated.
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Affiliation(s)
- F E Hurrell
- Department of Clinical Studies - Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - K J Drobatz
- Department of Clinical Studies - Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - R S Hess
- Department of Clinical Studies - Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
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Gleeson S, Mulroy E, Clarke DE. Lactation Ketoacidosis: An Unusual Entity and a Review of the Literature. Perm J 2016; 20:71-3. [PMID: 26909776 DOI: 10.7812/tpp/15-097] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A 31-year-old woman presented to the hospital with symptoms of nausea, malaise, and emesis. She was breastfeeding her 10-month-old infant. She was found to have severe ketoacidosis. The patient was not in diabetic ketoacidosis or alcoholic ketoacidosis; nor had she ingested any toxins. After she was admitted to the hospital, received intravenous fluids, and stopped breastfeeding, her symptoms resolved. She was found to have lactation ketoacidosis, an uncommon condition in humans. A review of all causes of ketoacidosis is presented with special emphasis on lactation ketocacidosis.
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Affiliation(s)
| | - Eoin Mulroy
- Registrar at the Dunedin Hospital in New Zealand.
| | - David E Clarke
- Consultant in Medicine at the Dunedin Hospital; and an Honorary Clinical Senior Lecturer at the University of Otago School of Medicine in Dunedin, New Zealand; Clinical Assistant Professor of Medicine at Stanford University School of Medicine; and a Hospitalist at the Santa Clara Medical Center in CA.
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20
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Ayed S, Bouguerba A, Ahmed P, Barchazs J, Boukari M, Goldgran-Toledano D, Bornstain C, Vincent F. Les pièges de l’acidocétose diabétique. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1113-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Thorley H, Porter K, Fleming C, Jones T, Kesten J, Marques E, Richards A, Savović J. Interventions for preventing or treating malnutrition in problem drinkers who are homeless or vulnerably housed: protocol for a systematic review. Syst Rev 2015; 4:131. [PMID: 26424296 PMCID: PMC4589081 DOI: 10.1186/s13643-015-0114-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 09/14/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Problem alcohol drinking in homeless and vulnerably housed people can lead to malnutrition, which is associated with complications such as alcohol-related brain damage. Homeless alcohol drinkers are likely to have worse health outcomes and different nutritional needs compared with housed alcohol-drinking persons. It is not clear whether interventions to improve nutritional status in this population have been effective. The purpose of this review is to assess the effectiveness and cost-effectiveness of interventions for preventing or correcting micronutrient deficiencies and other forms of malnutrition and related comorbidities in this population. METHODS/DESIGN A systematic search for studies of a nutrition-based intervention applied in the homeless or vulnerably housed population with problem drinking will be conducted. The following electronic databases will be systematically searched for relevant studies: MEDLINE, EMBASE, Web of Science, PsycINFO, CAB abstracts, CINAHL, Cochrane Public Health Group Register and Cochrane Drugs and Alcohol Group Register. Screening of identified abstracts for relevance and assessment of papers for inclusion will be done in duplicate. One reviewer will extract data from the studies and assess quality, and this will be checked by another reviewer. Discrepancies will be resolved by consensus. The primary outcomes are (mal)nutrition status or micronutrient deficiencies or change in (mal)nutrition status or micronutrient deficiencies, measures of liver damage and cognitive function. Secondary outcomes include comorbidities, quality of life and functional scales, resources used to deliver treatment, uptake/acceptability of the intervention and engagement with treatment services. Results will be analysed descriptively, and, if appropriate, meta-analyses will be performed. DISCUSSION The results of this review should help to inform the development of effective interventions that can be implemented in the community to improve the health of homeless people who are problem drinkers. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015024247.
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Affiliation(s)
- Helen Thorley
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK. .,School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - Katie Porter
- Bristol City Council, St Anne's House, St Anne's Road, Bristol, BS4 4AB, UK.
| | - Clare Fleming
- Compass Health, The Compass Centre, 1 Jamaica Street, Bristol, BS2 8JP, UK.
| | - Tim Jones
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK. .,School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - Joanna Kesten
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK. .,School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - Elsa Marques
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK. .,School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - Alison Richards
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK. .,School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - Jelena Savović
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK. .,School of Social and Community Medicine, University of Bristol, Bristol, UK.
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Trivisano M, Carapelle E, Martino T, Specchio LM. Bilateral putaminal necrosis and bronopol toxicity. BMJ Case Rep 2015; 2015:bcr-2014-206405. [PMID: 25697297 DOI: 10.1136/bcr-2014-206405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Among alcohols, methanol intoxication is the most frequently associated with cerebral toxicity, causing retinal damage and putaminal necrosis. This consequence is believed to be due to the transformation of methanol into formic acid. We describe the case of a patient who presented with acute impairment of consciousness and tetraparesis after she had been drinking several bottles of a topical antiseptic solution (Lysoform Medical) containing 2-bromo-2-nitro-1,3-propandiol (bronopol) among excipients, in order to lose weight during previous months. Moreover, she had been on a strict slimming diet. Soon after admission, a severe respiratory and metabolic impairment became rapidly evident, requiring an intensive care unit admission. Cerebral MRI showed the presence of bilateral putaminal necrosis. She recovered in 10 days, surprisingly, without any evident clinical neurological signs. Methanol, also bronopol, when diluted in aqueous solution, at warm temperature and/or higher pH, may release formaldehyde, which is converted into formic acid, a basal ganglia toxic compound.
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Affiliation(s)
- Marina Trivisano
- Clinic of Nervous System Diseases, Ospedali Riuniti Foggia, University of Foggia, Foggia, Italy Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Elena Carapelle
- Clinic of Nervous System Diseases, Ospedali Riuniti Foggia, University of Foggia, Foggia, Italy
| | - Tommaso Martino
- Clinic of Nervous System Diseases, Ospedali Riuniti Foggia, University of Foggia, Foggia, Italy
| | - Luigi Maria Specchio
- Clinic of Nervous System Diseases, Ospedali Riuniti Foggia, University of Foggia, Foggia, Italy
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Palmiere C, de Froidmont S, Mangin P, Werner D, Lobrinus JA. Ketoacidosis and Adrenocortical Insufficiency. J Forensic Sci 2014; 59:1146-52. [DOI: 10.1111/1556-4029.12446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 02/01/2013] [Accepted: 04/28/2013] [Indexed: 01/26/2023]
Affiliation(s)
- Cristian Palmiere
- University Centre of Legal Medicine; Rue du Bugnon 21 1011 Lausanne Switzerland
| | | | - Patrice Mangin
- University Centre of Legal Medicine; Rue du Bugnon 21 1011 Lausanne Switzerland
| | - Dominique Werner
- Laboratory of Clinical Chemistry; Lausanne University Hospital; 1011 Lausanne Switzerland
| | - Johannes A. Lobrinus
- Division of Clinical Pathology; Geneva University Hospital; 4 Rue Gabrielle-Perret-Gentil 1211 Geneva Switzerland
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Abstract
Various unmeasured anions other than lactate appear in the blood of septic patients, including ketones. However, the occurrence of sepsis-induced ketoacidosis without diabetes mellitus has not been reported to date. We herein describe severe ketoacidosis in a patient with septic shock despite the absence of diabetes, alcohol and starvation. A 76-year-old woman presented with septic shock due to acute obstructive cholangitis. She exhibited ketoacidosis and a remarkably strong ion gap, except for ketones. Sepsis alone may lead to ketoacidosis in patients without diabetes under specific conditions. The accumulation of ketones and other strong anions can occur in cases involving a decreased metabolic function. There may be a pathological condition called septic ketoacidosis.
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Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Japan
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