1
|
Usman A, Mustafa N, Iqbal SP, Hasan MZ, Shaikh MF, Dujaili JA, Gan SH. Mapping the role of pH-adjusted potassium in diabetic ketoacidosis: Hypokalemia and the patient outcomes. Int J Clin Pract 2021; 75:e14315. [PMID: 33934480 DOI: 10.1111/ijcp.14315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Incidence of hypokalemia during the management of diabetic ketoacidosis (DKA) is high despite detailed potassium replacement guidelines in its treatment. AIM We aimed to find the role of pH-adjusted potassium (pHK ) in the development of hypokalemia, and their mutual impact on patient outcomes during DKA management. METHODOLOGY Adult DKA patient's admission data of preceding 3 years (2015-2017) were retrospectively clerked. Outcomes of interest were time to develop hypokalemia and to terminate emergency department (ED) care (hours), severity of hypokalemia and hospitalisation length (days). Linear regression was used to determine significant associations/predictors. RESULTS The study was concluded on 85 patients. Hypokalemia was observed in nearly 3/4th of all admissions and occurred by the time of ED care termination. Each 1 mmol/L increase in pHK significantly (a) reduced the degree of hypokalemia by 0.07 mmol/L, (b) delayed time to develop hypokalemia by 4.58 hours, (c) and reduced the ED care time by 1.28 hours. Arterial pH was the other factor significantly delaying time to develop hypokalemia (36.25 hours) and facilitating early discharge from ED (13.86 hours). Moreover, each 1 mmol/L reduction in the degree of hypokalemia increased hospitalisation length by 1.86 days. Though significant, acute kidney injury negligibly increased hospitalisation length by 0.01 days. CONCLUSION pH-adjusted potassium shall be used as a marker for hypokalemia and to initiate potassium replacement instead of measured serum potassium in DKA. Utilising pHK will help to avoid hypokalemia, reduce its severity and shorten ED care which will subsequently reduce hospitalisation length. We expect pHK to improve pharmacoeconomics in the future.
Collapse
Affiliation(s)
- Atif Usman
- School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
| | - Norlaila Mustafa
- Department of Endocrinology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Saleem Perwaiz Iqbal
- Department of Community Medicine, Shalamar Institute of Health Sciences, Lahore, Pakistan
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | - Md Zobaer Hasan
- School of Science, Monash University Malaysia, Selangor, Malaysia
| | - Mohd Farooq Shaikh
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | | | - Siew Hua Gan
- School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
| |
Collapse
|
2
|
Kraus FB, Kocijancic M, Kluttig A, Ludwig-Kraus B. Test validation, method comparison and reference range for the measurement of β-hydroxybutyrate in peripheral blood samples. Biochem Med (Zagreb) 2020; 30:010707. [PMID: 32063730 PMCID: PMC6999181 DOI: 10.11613/bm.2020.010707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/13/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction The measurement of β-hydroxybutyrate (βOHB) concentrations is a corner stone of the diagnosis of diabetic ketoacidosis and other ketonic states. The aim of this study was to perform a validation of a peripheral blood βOHB assay (Randox) on a Roche cobas c502 analyser and to establish a βOHB reference range for the validated assay. Materials and methods Precision, linearity and limit of detection and blank (LoD, LoB) were determined according to Clinical and Laboratory Standards Institute (CLSI) EP05-A3, EP 06-A and EP17-A2 guidelines, using commercial control material and residual patient sample pools. As method comparison, for 190 semi-quantitative measurements of urine ketones we determined the corresponding βOHB blood concentration. The reference range was based on the CLSI C28-A3 guideline, using 304 randomly selected serum samples from population based German National Cohort (GNC) study. Results Coefficients of variation for the validated assay ranged from 1.5% for high concentrations (3.1 mmol/L) to 6.5% for low concentrations (0.1 mmol/L). Detection capacity was LoB = 0.011 mmol/L and LoD = 0.037 mmol/L. Linearity of the assay ranged from 0.10 to 3.95 mmol/L. The agreement between the semi-quantitative urine ketone test and the βOHB blood test was moderate (Kappa = 0.66). The obtained 95% serum reference range was estimated as 0.02 to 0.28 mmol/l βOHB. Conclusions The Ranbut βOHB assay showed good precision and analytical performance. Our results confirm that βOHB measurement in peripheral blood is indeed a preferable alternative to the semi-quantitative measurement of urine ketones.
Collapse
Affiliation(s)
- Frank Bernhard Kraus
- Central Laboratory, University Hospital Halle, Halle (Saale), Germany; Institute of Biology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Marija Kocijancic
- Central Laboratory, University Hospital Halle, Halle (Saale), Germany
| | - Alexander Kluttig
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther- University Halle-Wittenberg, Halle (Saale), Germany
| | | |
Collapse
|
3
|
Dhatariya K. Blood Ketones: Measurement, Interpretation, Limitations, and Utility in the Management of Diabetic Ketoacidosis. Rev Diabet Stud 2017; 13:217-225. [PMID: 28278308 DOI: 10.1900/rds.2016.13.217] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Diabetic ketoacidosis (DKA) remains a common medical emergency. Over the last few years, new national guidelines have changed the focus in managing the condition from being glucose-centered to ketone-centered. With the advent of advancing technology and the increasing use of hand-held, point-of-care ketone meters, greater emphasis is placed on making treatment decisions based on these readings. Furthermore, recent warnings about euglycemic DKA occurring in people with diabetes using sodium-glucose co-transporter 2 (SGLT-2) inhibitors urge clinicians to inform their patients of this condition and possible testing options. This review describes the reasons for a change in treating DKA, and outlines the benefits and limitations of using ketone readings, in particular highlighting the difference between urine and capillary readings.
Collapse
Affiliation(s)
- Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK
| |
Collapse
|
4
|
Wang CC, Hennek JW, Ainla A, Kumar AA, Lan WJ, Im J, Smith B, Zhao M, Whitesides GM. A Paper-Based "Pop-up" Electrochemical Device for Analysis of Beta-Hydroxybutyrate. Anal Chem 2016; 88:6326-33. [PMID: 27243791 PMCID: PMC5633928 DOI: 10.1021/acs.analchem.6b00568] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This paper describes the design and fabrication of a "pop-up" electrochemical paper-based analytical device (pop-up-EPAD) to measure beta-hydroxybutyrate (BHB)-a biomarker for diabetic ketoacidosis-using a commercial combination BHB/glucometer. Pop-up-EPADs are inspired by pop-up greeting cards and children's books. They are made from a single sheet of paper folded into a three-dimensional (3D) device that changes shape, and fluidic and electrical connectivity, by simply folding and unfolding the structure. The reconfigurable 3D structure makes it possible to change the fluidic path and to control timing; it also provides mechanical support for the folded and unfolded structures that enables good registration and repeatability on folding. A pop-up-EPAD designed to detect BHB shows performance comparable to commercially available plastic test strips over the clinically relevant range of BHB in blood when used with a commercial glucometer that integrates the ability to measure glucose and BHB (combination BHB/glucometer). With simple modifications of the electrode and the design of the fluidic path, the pop-up-EPAD also detects BHB in buffer using a simple glucometer-a device that is more available than the combination BHB/glucometer. Strategies that use a "3D pop-up"-that is, large-scale changes in 3D structure and fluidic paths-by folding/unfolding add functionality to EPADs (e.g., controlled timing, fluidic handling and path programming, control over complex sequences of steps, and alterations in electrical connectivity) and should enable the development of new classes of paper-based diagnostic devices.
Collapse
Affiliation(s)
- Chien-Chung Wang
- Department of Chemistry & Chemical Biology, Harvard University, 12 Oxford Street, Cambridge, MA 02138, USA
| | - Jonathan W. Hennek
- Department of Chemistry & Chemical Biology, Harvard University, 12 Oxford Street, Cambridge, MA 02138, USA
| | - Alar Ainla
- Department of Chemistry & Chemical Biology, Harvard University, 12 Oxford Street, Cambridge, MA 02138, USA
| | - Ashok A. Kumar
- Department of Chemistry & Chemical Biology, Harvard University, 12 Oxford Street, Cambridge, MA 02138, USA
| | - Wen-Jie Lan
- Department of Chemistry & Chemical Biology, Harvard University, 12 Oxford Street, Cambridge, MA 02138, USA
| | - Judy Im
- Department of Chemistry & Chemical Biology, Harvard University, 12 Oxford Street, Cambridge, MA 02138, USA
| | - Barbara Smith
- Department of Chemistry & Chemical Biology, Harvard University, 12 Oxford Street, Cambridge, MA 02138, USA
| | - Mengxia Zhao
- Department of Chemistry & Chemical Biology, Harvard University, 12 Oxford Street, Cambridge, MA 02138, USA
| | - George M. Whitesides
- Department of Chemistry & Chemical Biology, Harvard University, 12 Oxford Street, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, 60 Oxford Street, Cambridge, MA 02138, USA
- Kavli Institute for Bionano Science & Technology, Harvard University, 29 Oxford Street, Cambridge, MA 02138, USA
| |
Collapse
|
5
|
Misra S, Oliver NS. Utility of ketone measurement in the prevention, diagnosis and management of diabetic ketoacidosis. Diabet Med 2015; 32:14-23. [PMID: 25307274 DOI: 10.1111/dme.12604] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 07/10/2014] [Accepted: 10/06/2014] [Indexed: 11/28/2022]
Abstract
Ketone measurement is advocated for the diagnosis of diabetic ketoacidosis and assessment of its severity. Assessing the evidence base for ketone measurement in clinical practice is challenging because multiple methods are available but there is a lack of consensus about which is preferable. Evaluating the utility of ketone measurement is additionally problematic because of variability in the biochemical definition of ketoacidosis internationally and in the proposed thresholds for ketone measures. This has led to conflicting guidance from expert bodies on how ketone measurement should be used in the management of ketoacidosis. The development of point-of-care devices that can reliably measure the capillary blood ketone β-hydroxybutyrate (BOHB) has widened the spectrum of applications of ketone measurement, but whether the evidence base supporting these applications is robust enough to warrant their incorporation into routine clinical practice remains unclear. The imprecision of capillary blood ketone measures at higher values, the lack of availability of routine laboratory-based assays for BOHB and the continued cost-effectiveness of urine ketone assessment prompt further discussion on the role of capillary blood ketone assessment in ketoacidosis. In the present article, we review the various existing methods of ketone measurement, the precision of capillary blood ketone as compared with other measures, its diagnostic accuracy in predicting ketoacidosis and other clinical applications including prevention, assessment of severity and resolution of ketoacidosis.
Collapse
Affiliation(s)
- S Misra
- Department of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK; Clincal Biochemistry and Metabolic Medicine, Imperial Healthcare NHS Trust, London, UK
| | | |
Collapse
|
6
|
Improving Glucose Management with Point-of-Care Testing in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2014. [DOI: 10.1007/s40138-014-0048-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
7
|
Reply to the letter by Dr. Palmiere and Dr. Mangin. Leg Med (Tokyo) 2012. [DOI: 10.1016/j.legalmed.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
8
|
Arora S, Menchine M. The role of point-of-care β-hydroxybutyrate testing in the diagnosis of diabetic ketoacidosis: a review. Hosp Pract (1995) 2012; 40:73-78. [PMID: 22615081 DOI: 10.3810/hp.2012.04.972] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The number of patients with diabetes and diabetes-related complications is increasing. Rapid and accurate diagnosis is key to efficiently providing the appropriate level of care for patients with diabetes. When faced with a hyperglycemic patient (ie, blood glucose level > 250 mg/dL), the prevailing attitude among health care providers is to "think worst first," and common clinical practice is to perform an evaluation for diabetic ketoacidosis (DKA). Traditionally, diagnosing DKA in accordance with the American Diabetes Association guidelines requires performing ≥ 2 (possibly 3) tests to obtain measurements for blood glucose, serum bicarbonate, serum pH, and serum anion gap levels, as well as measurements of either urine or serum ketone bodies. Recently, commercial point-of-care β-hydroxybutyrate measurement devices have become readily accessible and less expensive. These devices offer the potential to simplify clinicians' diagnostic approach to hyperglycemic patients. In this evidence-based literature review, we describe the use of point-of-care β-hydroxybutyrate testing for diagnosing DKA, and discuss its limitations in determining DKA severity.
Collapse
Affiliation(s)
- Sanjay Arora
- Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA.
| | | |
Collapse
|