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Tekin B, Righi F, Quinton R. Renal Tubular Epithelial Subnuclear Vacuolization in Hypothermia and Diabetic Ketoacidosis-A Retrospective Autopsy Study. Am J Forensic Med Pathol 2022; 43:23-27. [PMID: 34054015 DOI: 10.1097/paf.0000000000000692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Subnuclear vacuolization of the renal tubular epithelium refers to discrete lipid vacuoles displacing the nuclei toward the lumen. This phenomenon has been associated with conditions sharing fatal ketoacidosis as a common denominator. This retrospective study aimed to investigate renal tubular epithelial subnuclear vacuolization and other postmortem examination findings in fatal hypothermia and diabetic ketoacidosis (DKA) cases.Fourteen cases with hypothermia and 19 cases with DKA were included. More cases with DKA had focal or diffuse subnuclear vacuolization compared with hypothermia cases (89% vs 43%; P = 0.007). In 6 cases with DKA, formalin pigment was detected within subnuclear vacuoles, whereas no case with hypothermia had formalin pigment deposition. Comparative analyses of hypothermia and DKA cases revealed further differences: Vitreous beta-hydroxybutyrate was higher in the DKA group compared with the hypothermia group (P = 0.044), whereas blood ethanol concentrations were higher in the latter (P = 0.008). Hypothermia cases were older compared with the DKA cases (P = 0.022).When all cases were included in the statistical analysis, cases with subnuclear vacuolization had higher vitreous beta-hydroxybutyrate and blood ethanol concentrations (P = 0.029 and 0.023, respectively). The findings corroborate the results of previous studies suggesting a link between subnuclear vacuolization and increased levels of ketoacidosis.
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Affiliation(s)
- Burak Tekin
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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Ichimata S, Hata Y, Nishida N. Clinicopathologic Appearance of Advanced Ketoacidosis With Basal Vacuolation in Renal Tubules. Arch Pathol Lab Med 2021; 146:1102-1113. [PMID: 34936698 DOI: 10.5858/arpa.2021-0226-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Basal vacuolization (BV) in renal tubules is a histopathologic hallmark of advanced ketoacidosis that enables us to retrospectively diagnose these cases. OBJECTIVE.— To clarify the pathologic background and serologic findings of ketoacidosis with BV, and to reveal the pathologic findings by each pathologic background. DESIGN.— We examined 664 serial autopsy cases. A systemic histopathologic examination and measurement of serum β-hydroxybutyrate concentration were performed for the cases with BV. The extent of steatosis and fibrosis in the organs and the degree of coronary artery stenosis were semiquantitatively investigated. Immunohistochemistry for adipophilin was also performed to analyze its usefulness for the pathologic diagnosis. RESULTS.— Basal vacuolization was found in 16 cases, all of which showed a pathologic serum β-hydroxybutyrate concentration. The main background of ketoacidosis was considered as alcohol abuse in 6 cases, diabetes in 5, malnutrition in 3, and hypothermia and infection in 1 case each. Severe hepatic fibrosis was observed only in the alcohol-abuser group. Moreover, cardiac steatosis was more severe in patients with possible alcohol abuse than in those with other causes. Immunohistochemistry for adipophilin showed immunoreactivity consistent with BV in 13 of 16 cases. There was no correlation between β-hydroxybutyrate concentration and either the postmortem or storage interval. CONCLUSIONS.— Basal vacuolization may be a useful finding for detecting ketoacidosis cases in a postmortem investigation. Serum β-hydroxybutyrate was a stable and reliable compound for the definitive diagnosis of ketoacidosis in such cases. The present study showed that pathologic changes in some organs may vary by each pathologic background of ketoacidosis with BV.
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Affiliation(s)
- Shojiro Ichimata
- From the Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yukiko Hata
- From the Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Naoki Nishida
- From the Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
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Weckx R, Goossens C, Derde S, Pauwels L, Vander Perre S, Van den Bergh G, Langouche L. Identification of the toxic threshold of 3-hydroxybutyrate-sodium supplementation in septic mice. BMC Pharmacol Toxicol 2021; 22:50. [PMID: 34544493 PMCID: PMC8454128 DOI: 10.1186/s40360-021-00517-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 09/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In septic mice, supplementing parenteral nutrition with 150 mg/day 3-hydroxybutyrate-sodium-salt (3HB-Na) has previously shown to prevent muscle weakness without obvious toxicity. The main objective of this study was to identify the toxic threshold of 3HB-Na supplementation in septic mice, prior to translation of this promising intervention to human use. METHODS In a centrally-catheterized, antibiotic-treated, fluid-resuscitated, parenterally fed mouse model of prolonged sepsis, we compared with placebo the effects of stepwise escalating doses starting from 150 mg/day 3HB-Na on illness severity and mortality (n = 103). For 5-day survivors, also the impact on ex-vivo-measured muscle force, blood electrolytes, and markers of vital organ inflammation/damage was documented. RESULTS By doubling the reference dose of 150 mg/day to 300 mg/day 3HB-Na, illness severity scores doubled (p = 0.004) and mortality increased from 30.4 to 87.5 % (p = 0.002). De-escalating this dose to 225 mg still increased mortality (p ≤ 0.03) and reducing the dose to 180 mg/day still increased illness severity (p ≤ 0.04). Doses of 180 mg/day and higher caused more pronounced metabolic alkalosis and hypernatremia (p ≤ 0.04) and increased markers of kidney damage (p ≤ 0.05). Doses of 225 mg/day 3HB-Na and higher caused dehydration of brain and lungs (p ≤ 0.05) and increased markers of hippocampal neuronal damage and inflammation (p ≤ 0.02). Among survivors, 150 mg/day and 180 mg/day increased muscle force compared with placebo (p ≤ 0.05) up to healthy control levels (p ≥ 0.3). CONCLUSIONS This study indicates that 150 mg/day 3HB-Na supplementation prevented sepsis-induced muscle weakness in mice. However, this dose appeared maximally effective though close to the toxic threshold, possibly in part explained by excessive Na+ intake with 3HB-Na. Although lower doses were not tested and thus might still hold therapeutic potential, the current results point towards a low toxic threshold for the clinical use of ketone salts in human critically ill patients. Whether 3HB-esters are equally effective and less toxic should be investigated.
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Affiliation(s)
- Ruben Weckx
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Chloë Goossens
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Sarah Derde
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Lies Pauwels
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Sarah Vander Perre
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Greet Van den Bergh
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 bus 503, 3000, Leuven, Belgium.
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Myers SR, Glaser NS, Trainor JL, Nigrovic LE, Garro A, Tzimenatos L, Quayle KS, Kwok MY, Rewers A, Stoner MJ, Schunk JE, McManemy JK, Brown KM, DePiero AD, Olsen CS, Casper TC, Ghetti S, Kuppermann N. Frequency and Risk Factors of Acute Kidney Injury During Diabetic Ketoacidosis in Children and Association With Neurocognitive Outcomes. JAMA Netw Open 2020; 3:e2025481. [PMID: 33275152 PMCID: PMC7718599 DOI: 10.1001/jamanetworkopen.2020.25481] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Acute kidney injury (AKI) occurs commonly during diabetic ketoacidosis (DKA) in children, but the underlying mechanisms and associations are unclear. OBJECTIVE To investigate risk factors for AKI and its association with neurocognitive outcomes in pediatric DKA. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a secondary analysis of data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in DKA Study, a prospective, multicenter, randomized clinical trial comparing fluid protocols for pediatric DKA in 13 US hospitals. Included DKA episodes occurred among children age younger than 18 years with blood glucose 300 mg/dL or greater and venous pH less than 7.25 or serum bicarbonate level less than 15 mEq/L. EXPOSURES DKA requiring intravenous insulin therapy. MAIN OUTCOMES AND MEASURES AKI occurrence and stage were assessed using serum creatinine measurements using Kidney Disease: Improving Global Outcomes criteria. DKA episodes with and without AKI were compared using univariable and multivariable methods, exploring associated factors. RESULTS Among 1359 DKA episodes (mean [SD] patient age, 11.6 [4.1] years; 727 [53.5%] girls; 651 patients [47.9%] with new-onset diabetes), AKI occurred in 584 episodes (43%; 95% CI, 40%-46%). A total of 252 AKI events (43%; 95% CI, 39%-47%) were stage 2 or 3. Multivariable analyses identified older age (adjusted odds ratio [AOR] per 1 year, 1.05; 95% CI, 1.00-1.09; P = .03), higher initial serum urea nitrogen (AOR per 1 mg/dL increase, 1.14; 95% CI, 1.11-1.18; P < .001), higher heart rate (AOR for 1-SD increase in z-score, 1.20; 95% CI, 1.09-1.32; P < .001), higher glucose-corrected sodium (AOR per 1 mEq/L increase, 1.03; 95% CI, 1.00-1.06; P = .001) and glucose concentrations (AOR per 100 mg/dL increase, 1.19; 95% CI, 1.07-1.32; P = .001), and lower pH (AOR per 0.1 increase, 0.63; 95% CI, 0.51-0.78; P < .001) as variables associated with AKI. Children with AKI, compared with those without, had lower scores on tests of short-term memory during DKA (mean [SD] digit span recall: 6.8 [2.4] vs 7.6 [2.2]; P = .02) and lower mean (SD) IQ scores 3 to 6 months after recovery from DKA (100.0 [12.2] vs 103.5 [13.2]; P = .005). Differences persisted after adjusting for DKA severity and demographic factors, including socioeconomic status. CONCLUSIONS AND RELEVANCE These findings suggest that AKI may occur more frequently in children with greater acidosis and circulatory volume depletion during DKA and may be part of a pattern of multiple organ injury involving the kidneys and brain.
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Affiliation(s)
- Sage R. Myers
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nicole S. Glaser
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jennifer L. Trainor
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Aris Garro
- Department of Emergency Medicine, Rhode Island Hospital, Providence
- Department of Pediatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Kimberly S. Quayle
- Division of Emergency Medicine, St Louis Children’s Hospital, St Louis, Missouri
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Maria Y. Kwok
- Division of Emergency Medicine, NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Arleta Rewers
- Division of Emergency Medicine, Colorado Children’s Hospital, Denver
- Department of Pediatrics, University of Colorado–Denver School of Medicine, Aurora
| | - Michael J. Stoner
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus
| | - Jeff E. Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Julie K. McManemy
- Division of Emergency Medicine, Texas Children’s Hospital, Houston
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kathleen M. Brown
- Division of Emergency Medicine, Children’s National Medical Center, Washington, District of Columbia
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Andrew D. DePiero
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Simona Ghetti
- Department of Psychology, UC Davis Health, University of California School of Medicine, Sacramento
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
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A diabetic ketoacidosis in a context of hyperglycemia addiction. Int J Legal Med 2017; 132:787-790. [PMID: 29034415 DOI: 10.1007/s00414-017-1716-1] [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: 08/21/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
Abstract
We herein present a case of a 20-year-old woman who suffered from type I diabetes mellitus and died from a diabetic ketoacidosis in a context of addiction to hyperglycemia. Diabetic ketoacidosis is a lethal complication of insulin-dependent diabetes mellitus, which can result from insulin therapy stoppage. This can occur voluntarily with suicidal intent or involuntarily due to treatment inaccessibility, forgotten injections, or material deficiency. A new possibility is investigated in our case study: hyperglycemia addiction. The patient was treated by insulin glargine and insulin aspartate. She regularly stopped insulin glargine injections seeking the asthenia sensation produced by hyperglycemia, keeping the insulin aspartate injections to treat the disabling symptom related to hyperketonemia.
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