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Theron IJ, Mason S, van Reenen M, Stander Z, Kleynhans L, Ronacher K, Loots DT. Characterizing poorly controlled type 2 diabetes using 1H-NMR metabolomics. Metabolomics 2024; 20:54. [PMID: 38734832 PMCID: PMC11088559 DOI: 10.1007/s11306-024-02127-w] [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: 02/27/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION The prevalence of type 2 diabetes has surged to epidemic proportions and despite treatment administration/adherence, some individuals experience poorly controlled diabetes. While existing literature explores metabolic changes in type 2 diabetes, understanding metabolic derangement in poorly controlled cases remains limited. OBJECTIVE This investigation aimed to characterize the urine metabolome of poorly controlled type 2 diabetes in a South African cohort. METHOD Using an untargeted proton nuclear magnetic resonance metabolomics approach, urine samples from 15 poorly controlled type 2 diabetes patients and 25 healthy controls were analyzed and statistically compared to identify differentiating metabolites. RESULTS The poorly controlled type 2 diabetes patients were characterized by elevated concentrations of various metabolites associated with changes to the macro-fuel pathways (including carbohydrate metabolism, ketogenesis, proteolysis, and the tricarboxylic acid cycle), autophagy and/or apoptosis, an uncontrolled diet, and kidney and liver damage. CONCLUSION These results indicate that inhibited cellular glucose uptake in poorly controlled type 2 diabetes significantly affects energy-producing pathways, leading to apoptosis and/or autophagy, ultimately contributing to kidney and mild liver damage. The study also suggests poor dietary compliance as a cause of the patient's uncontrolled glycemic state. Collectively these findings offer a first-time comprehensive overview of urine metabolic changes in poorly controlled type 2 diabetes and its association with secondary diseases, offering potential insights for more targeted treatment strategies to prevent disease progression, treatment efficacy, and diet/treatment compliance.
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Affiliation(s)
- Isabella J Theron
- Human Metabolomics, Department of Biochemistry, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Shayne Mason
- Human Metabolomics, Department of Biochemistry, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Mari van Reenen
- Human Metabolomics, Department of Biochemistry, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Zinandré Stander
- Human Metabolomics, Department of Biochemistry, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Léanie Kleynhans
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa
- Mater Research Institute, The University of Queensland, Translational Research Institute, Brisbane, Australia
| | - Katharina Ronacher
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa
- Mater Research Institute, The University of Queensland, Translational Research Institute, Brisbane, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Australia
| | - Du Toit Loots
- Human Metabolomics, Department of Biochemistry, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa.
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Tamaki K, Saito N, Tomita H. Serum 3-Hydroxybutyrate is Expected to Serve as One of the Supportive Diagnostic Markers of Persistent Idiopathic Dentoalveolar Pain (PDAP). J Pain Res 2023; 16:4005-4013. [PMID: 38026450 PMCID: PMC10676723 DOI: 10.2147/jpr.s436034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/12/2023] [Indexed: 12/01/2023] Open
Abstract
Background Persistent idiopathic dentoalveolar pain (PDAP), previously referred to as atypical odontalgia, is a chronic dental pain that occurs without signs of pathology. PDAP is considered a diagnosis of exclusion, and its definition is currently under refinement and remains ambiguous. The metabolite known as 3-hydroxybutyrate (3HB) has garnered significant interest as a potential indicator for both depression and chronic psychogenic pain. We investigated the characteristics of patients with PDAP and hypothesized that serum 3HB could support the diagnosis of PDAP. Subjects and Methods Forty-one patients with PDAP and 167 patients with odontogenic toothache were investigated regarding depression and anxiety scales in addition to the general dental evaluation. Blood tests including high-sensitivity CRP, HbA1c, and 3HB were performed for all patients. Associations between PDAP and patients' varying characteristics were investigated using hierarchical multivariate logistic regression analyses. Results There were more females, current smokers, patients with orofacial pain (such as temporomandibular joint pain, glossalgia, and headache), and people with elevated 3HB levels among patients with PDAP than among control participants. Multivariate logistic regression analyses predicting patients with PDAP identified the female sex (odds ratio [OR]: 4.16), current smoking (OR: 14.9), glossalgia (OR: 19.8) a high CES-D score (≥16) (OR: 5.98), and elevated serum 3HB (≥80 μmol/L) (OR: 18.4) factors significantly associated with PDAP. Conclusion Our results demonstrated that serum 3HB levels could be elevated in patients with PDAP compared to other types of odontogenic pain, although 3HB was not specific to PDAP. Based on our findings, five factors - female sex, current smoking, depressive tendencies, chronic orofacial pains, and high serum 3HB levels - could be useful for diagnosing PDAP.
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Affiliation(s)
- Katsuya Tamaki
- Department of Clinical Laboratory Medicine Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, 036-8562, Japan
- Tamaki Dental Clinic, Keison-Kai, Akita City, 010-0925, Japan
| | - Norihiro Saito
- Department of Clinical Laboratory Medicine Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, 036-8562, Japan
| | - Hirofumi Tomita
- Department of Clinical Laboratory Medicine Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, 036-8562, Japan
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, 036-8562, Japan
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3
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Lernmark Å, Metzger BE, Nathan DM, Kirkman MS. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Diabetes Care 2023; 46:e151-e199. [PMID: 37471273 PMCID: PMC10516260 DOI: 10.2337/dci23-0036] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/11/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially. APPROACH An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association for Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association. CONTENT Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (HbA1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of HbA1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed. SUMMARY The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.
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Affiliation(s)
- David B. Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
| | - Mark Arnold
- Department of Chemistry, University of Iowa, Iowa City, IA
| | - George L. Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, IL
| | - David E. Bruns
- Department of Pathology, University of Virginia Medical School, Charlottesville, VA
| | - Andrea R. Horvath
- New South Wales Health Pathology Department of Chemical Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital Malmö, Malmö, Sweden
| | - Boyd E. Metzger
- Division of Endocrinology, Northwestern University, The Feinberg School of Medicine, Chicago, IL
| | - David M. Nathan
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA
| | - M. Sue Kirkman
- Department of Medicine, University of North Carolina, Chapel Hill, NC
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4
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Lernmark Å, Metzger BE, Nathan DM, Kirkman MS. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Clin Chem 2023:hvad080. [PMID: 37473453 DOI: 10.1093/clinchem/hvad080] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/12/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially. APPROACH An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association of Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association. CONTENT Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (Hb A1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of Hb A1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed. SUMMARY The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, United States
| | - Mark Arnold
- Department of Chemistry, University of Iowa, Iowa City, IA, United States
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, ILUnited States
| | - David E Bruns
- Department of Pathology, University of Virginia Medical School, Charlottesville, VA, United States
| | - Andrea R Horvath
- New South Wales Health Pathology Department of Chemical Pathology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital Malmö, Malmö, Sweden
| | - Boyd E Metzger
- Division of Endocrinology, Northwestern University, The Feinberg School of Medicine, Chicago, IL, United States
| | - David M Nathan
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - M Sue Kirkman
- Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
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5
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Lazar I, Wizeman-Orlov D, Hazan G, Orbach A, Haim A, Cavari Y, Feinstein Y, Neeman E, Hershkovitz E, Faingelernt Y. The role of anion gap normalization time in the management of pediatric diabetic ketoacidosis. Front Pediatr 2023; 11:1198581. [PMID: 37334219 PMCID: PMC10275565 DOI: 10.3389/fped.2023.1198581] [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: 04/01/2023] [Accepted: 05/02/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction Our aims were to determine whether anion gap normalization time (AGNT) correlates with risk factors related to the severity of diabetic ketoacidosis (DKA) in children, and to characterize AGNT as a criterion for DKA resolution in children admitted with moderate or severe disease. Methods A ten-year retrospective cohort study of children admitted to the intensive care unit with DKA. We used a survival analysis approach to determine changes in serum glucose, bicarbonate, pH, and anion gap following admission. Using multivariate analysis, we examined associations between patients' demographic and laboratory characteristics with delayed normalization of the anion gap. Results A total of 95 patients were analyzed. The median AGNT was 8 h. Delayed AGNT (>8 h) correlated with pH < 7.1 and serum glucose >500 mg/dL. In multivariate analysis, glucose >500 mg/dL was associated with an increased risk for delayed AGNT, by 3.41 fold. Each 25 mg/dL elevation in glucose was associated with a 10% increment in risk for delayed AGNT. Median AGNT preceded median PICU discharge by 15 h (8 vs. 23 h). Discussion AGNT represents a return to normal glucose-based physiology and an improvement in dehydration. The correlation observed between delayed AGNT and markers of DKA severity supports the usefulness of AGNT for assessing DKA recovery.
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Affiliation(s)
- Isaac Lazar
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Dorit Wizeman-Orlov
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Guy Hazan
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pediatrics D, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Asaf Orbach
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Alon Haim
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pediatrics D, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Pediatric Endocrinology Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Yuval Cavari
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yael Feinstein
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Eitan Neeman
- Pediatric Intensive Care Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Eli Hershkovitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pediatrics D, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
- Pediatric Endocrinology Unit, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Yaniv Faingelernt
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pediatrics D, Saban Center of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
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Mastromauro C, Polidori N, Blasetti A, Comegna L, Chiarelli F, Mohn A, Giannini C. Insulin resistance relates to DKA severity and affects insulin requirement in children with type 1 diabetes at onset. Pediatr Diabetes 2022; 23:1613-1620. [PMID: 36183171 PMCID: PMC10092633 DOI: 10.1111/pedi.13424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/09/2022] [Accepted: 09/27/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Fluid and insulin treatments are the cornerstones of DKA management and indications on dosages are available. However, according to possible confounding factors, relevant data are still required to explain the different insulin dosages adopted at diabetes onset, particularly based upon insulin sensitivity. OBJECTIVE We aimed to explore whether DKA severity is related to different insulin sensitivity states, thus resulting in different insulin requirement at diabetes onset. METHODS Retrospective data from hospital records of 62 newly diagnosed children with type 1 diabetes with DKA were analyzed. The population was divided into three groups: severe, moderate, and mild DKA. Anthropometric, laboratory test, insulin, and glucose administration data were analyzed. The Glucose Infusion Rate (GIR), Insulin Infusion Rate (IIR), and GIR/IIR were calculated and used as indexes of insulin sensitivity. The area under the curve (AUC) for insulin and glucose infusion was calculated. RESULTS Moving among the three groups, IIR decreased while GIR and GIR/IIR increased from severe to mild DKA group (all p < 0.01). A similar trend was documented for AUC-insulin and AUC-glucose as well as AUC-glucose/AUC-insulin ratio. The Spearman correlation showed a negative correlation between pH and both IIR and AUC-Insulin as well as a positive correlation between pH and both GIR/IIR and AUC-glucose/AUC-insulin ratio. CONCLUSIONS Subjects with severe DKA have a higher insulin requirement compared to those with less severe DKA. Significant differences in terms of insulin sensitivity might be documented according to the severity of DKA, which might result in tailored insulin pH requirement in children with new onset type 1 diabetes.
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Affiliation(s)
| | - Nella Polidori
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Laura Comegna
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center for Advanced Studies and Technology - CAST (ex CesSI-MeT), University of Chieti, Chieti, Italy
| | - Angelika Mohn
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center for Advanced Studies and Technology - CAST (ex CesSI-MeT), University of Chieti, Chieti, Italy
| | - Cosimo Giannini
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center for Advanced Studies and Technology - CAST (ex CesSI-MeT), University of Chieti, Chieti, Italy
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Saikia D, Mittal M, Kanakaraju C, Dhingra D, Kumar M. Efficacy and Safety of Low Dose Insulin Infusion against Standard Dose Insulin Infusion in Children with Diabetic Ketoacidosis- An Open Labelled Randomized Controlled Trial. Indian J Endocrinol Metab 2022; 26:173-179. [PMID: 35873943 PMCID: PMC9302420 DOI: 10.4103/ijem.ijem_50_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/12/2022] [Accepted: 03/30/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of low dose insulin infusion (0.05 U/kg/h) against the standard dose insulin infusion (0.1 U/kg/h) in children with diabetic ketoacidosis. METHOD Children (age <12 years, n = 30) presenting with diabetic ketoacidosis were enrolled and randomised to receive insulin infusion either as 0.05 U/kg/h (low dose) or 0.1 U/kg/h (standard dose) as an open labelled randomised controlled trial. The rest of the management was identical in both groups. The time taken for resolution of acidosis (pH ≥7.3 and HCO3 ≥15) was the primary outcome variable. The secondary outcome variables included the time taken until a decline in blood glucose to 250 mg/dl, the proportion of children developing hypoglycemia and hypokalemia, and any treatment failure. RESULTS The two groups were similar with respect to mean age, weight and gender distribution. New-onset diabetes was diagnosed on 24/30. The mean ± SD time for resolution of acidosis was similar between the groups; 27.0 ± 6.1 hours in the low dose group vs 23.4 ± 7.3 hours in standard dose group, P = 0.16. The mean time for the decline in blood glucose to 250 mg/dl was 13.0 ± 5.9 hours in low dose vs 11.6 ± 6.0 hours in standard dose group, P = 0.52. A lesser proportion of participants developed hypoglycemia and hypokalemia in the low dose group, though not statistically significant. There was no incidence of treatment failure in either group. CONCLUSION Low dose insulin infusion is equally effective and safe as standard dose insulin infusion in children with diabetic ketoacidosis.
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Affiliation(s)
- Diganta Saikia
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Medha Mittal
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | | | - Dhulika Dhingra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Manish Kumar
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
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9
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Yismaw BF, Leulseged TW. Subcutaneous regular insulin use for the management of diabetic ketoacidosis in resource limited setting. J Pediatr Endocrinol Metab 2022; 35:179-184. [PMID: 34563105 DOI: 10.1515/jpem-2021-0527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/13/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The standard recommendation of insulin therapy for patients with DKA is the administration of slow continuous intravenous (IV) regular insulin. Currently subcutaneous insulin is being recommended as an alternative treatment of DKA in mild and moderate cases in resource-limited settings. The purpose of this study was to assess the effectiveness and safety of six-hourly subcutaneous regular insulin use for the treatment of DKA among children with type one diabetes mellitus. METHODS A retrospective cohort study was conducted among 224 DKA episodes which occurred in 161 children who were treated at St. Paul's Hospital Millennium Medical College in Addis Ababa, Ethiopia, from November 2015 to November 2020. RESULTS Majority (68.8%) of the episodes occurred in newly diagnosed cases. The median time for urinary ketones clearance was 24 h. DKA severity was found to be the only significant predictor of time to DKA resolution. Only 13 (5.8%) were treated at the pediatric intensive care unit (PICU), and 27 (12.1%) developed complications during management. No death or neurological complications observed. CONCLUSIONS The six-hourly subcutaneous regular insulin use was found to be safe and effective alternative to slow IV insulin infusion for the treatment of DKA in a non PICU setting. As it resulted in minimum morbidity and no mortality, we recommend its use in the treatment of DKA irrespective of its severity. It can also decrease the health care cost and patients' inconvenience.
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Affiliation(s)
- Bereket F Yismaw
- Department of Pediatrics, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Tigist W Leulseged
- Department of Internal Medicine, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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10
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Kilpatrick ES, Butler AE, Ostlundh L, Atkin SL, Sacks DB. Controversies Around the Measurement of Blood Ketones to Diagnose and Manage Diabetic Ketoacidosis. Diabetes Care 2022; 45:267-272. [PMID: 35050366 PMCID: PMC8897555 DOI: 10.2337/dc21-2279] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/12/2021] [Indexed: 02/03/2023]
Abstract
The measurement of blood ketones in preference to urine ketones has become a well-established tool in the diagnosis and management of diabetic ketoacidosis (DKA). However, there remains considerable disparity between diabetes guidelines regarding if, how, and when this test should be used. While recent guidelines now mainly emphasize blood measurement, several issues nonetheless remain. Many laboratories still measure blood ketones using a semiquantitative test that does not measure the predominant ketone, β-hydroxybutyrate (BOHB), which may hinder patient management. Even when BOHB is measured, the evidence for cutoffs used in DKA diagnosis or exclusion is limited, while its use in gauging severity, treatment progress, and resolution is not fully clear. Lastly, although employing point-of-care meters instead of a laboratory for BOHB measurement brings undoubted benefits, this approach has its own challenges. This article provides a perspective on these topics to complement current recommendations and to suggest how future research may improve its use in the DKA context.
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Affiliation(s)
- Eric S. Kilpatrick
- Department of Clinical Biochemistry, Manchester Royal Infirmary, Manchester, U.K
| | - Alexandra E. Butler
- Department of Postgraduate Studies and Research, Royal College of Surgeons in Ireland, Medical University of Bahrain, Busaiteen, Bahrain
| | - Linda Ostlundh
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain
| | - Stephen L. Atkin
- Department of Postgraduate Studies and Research, Royal College of Surgeons in Ireland, Medical University of Bahrain, Busaiteen, Bahrain
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11
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Boß K, Kirk S. Pflegerische Herausforderungen in der Betreuung und Anleitung von Kindern mit Diabetes mellitus Typ 1 und ihren Betreuungspersonen. DIABETOLOGE 2021. [DOI: 10.1007/s11428-021-00837-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Yuyama Y, Kawamura T, Nishikawa-Nakamura N, Hotta Y, Hashimura K, Hashimoto T, Hirose M, Higashide T, Hamazaki T. Relationship Between Bedside Ketone Levels and Time to Resolution of Diabetic Ketoacidosis: A Retrospective Cohort Study. Diabetes Ther 2021; 12:3055-3066. [PMID: 34628606 PMCID: PMC8586106 DOI: 10.1007/s13300-021-01167-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/29/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION There is no information on the factors that influence the time required to induce resolution of diabetic ketoacidosis (DKA). New methods are currently available for bedside measurement of serum 3-hydroxybutyrate (3HB). The aim of this study was to determine the relationship between serum 3HB and the time to DKA resolution. METHODS We reviewed the medical records of patients with type 1 diabetes (T1D) and a history of DKA who were admitted to the Department of Pediatrics, Osaka City University Hospital, between November 2008 and October 2018. DKA resolution was defined as 3HB below 1.0 mmol/L as measured by a bedside ketone meter. RESULTS Data of 52 T1D-DKA episodes were analyzed (median age, 8.0 years; 20 male patients; 32 female patients; new T1D diagnosis, n = 13; established diagnosis, n = 39). In all cases, correction of serum 3HB was an important aspect of T1D management. The median time to DKA resolution (defined as the time from the start of insulin infusion until the fall of 3HB level to below 1.0 mmol/L) was 11 and 10 h in new and established T1D cases, respectively. 3HB on admission and the required insulin infusion dose per body weight, but not blood pH level on admission, correlated with time to DKA resolution. There was no relationship between blood pH level and 3HB on admission. CONCLUSIONS Our results showed that DKA resolution could be achieved within 10-11 h when DKA treatment is guided by bedside 3HB monitoring without any severe complications. Blood 3HB level is a potentially suitable marker for the severity and resolution of DKA.
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Affiliation(s)
- Yoshihiko Yuyama
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Asahi-cho 1-4-3, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Tomoyuki Kawamura
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Asahi-cho 1-4-3, Abeno-ku, Osaka City, Osaka, 545-8585, Japan.
| | - Naoko Nishikawa-Nakamura
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Asahi-cho 1-4-3, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Yuko Hotta
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Asahi-cho 1-4-3, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Kayako Hashimura
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Asahi-cho 1-4-3, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Tomomi Hashimoto
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Asahi-cho 1-4-3, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Masakazu Hirose
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Asahi-cho 1-4-3, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Takashi Higashide
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Asahi-cho 1-4-3, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
| | - Takashi Hamazaki
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Asahi-cho 1-4-3, Abeno-ku, Osaka City, Osaka, 545-8585, Japan
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Rameshkumar R, Satheesh P, Jain P, Anbazhagan J, Abraham S, Subramani S, Parameswaran N, Mahadevan S. Low-Dose (0.05 Unit/kg/hour) vs Standard-Dose (0.1 Unit/kg/hour) Insulin in the Management of Pediatric Diabetic Ketoacidosis: A Randomized Double-Blind Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2255-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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14
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Saito N, Itoga M, Minakawa S, Kayaba H. Serum 3-Hydroxybutyrate in Patients with Psychogenic Somatoform Symptoms May Be a Predictor of the Effectiveness of Sertraline and Venlafaxine. Int J Gen Med 2021; 14:1785-1795. [PMID: 34007205 PMCID: PMC8121269 DOI: 10.2147/ijgm.s300517] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are often used to treat outpatients with psychogenic somatoform symptoms but prove ineffective in some cases. The metabolite 3-hydroxybutyrate (3HB) is currently attracting attention as a marker of the severity of depression. We investigated whether serum 3HB levels in patients with psychogenic somatoform symptoms can predict the effectiveness of sertraline and venlafaxine. Patients and Methods Physical and psychiatric problems were assessed in 132 outpatients, and symptomatic response and serum 3HB concentrations were examined before and after treatment with sertraline (50 mg/day) or venlafaxine (75 mg/day). Results In 30.3% of patients with psychogenic symptoms, serum 3HB was above the upper limit of normal (<80 μmol/L). According to multiple logistic regression analysis, only episodes of suicidal ideation showed a significant positive association with elevated 3HB (odds ratio 10.2; 95% confidence interval (CI) 2.46–42.2). The sensitivity of 3HB for the effectiveness of sertraline or venlafaxine for psychosomatic symptoms was 44.6%, but specificity was 93.9%. Hierarchical multiple logistic regression analysis identified 3HB as a better predictor of the effectiveness of medication (odds ratio 10.0; 95% CI, 2.49–40.3) than episodes of suicidal ideation. Conclusion The present findings suggest that high serum 3HB levels in patients with psychogenic somatoform symptoms may be associated with suicidal ideation and the effectiveness of sertraline and venlafaxine at low to intermediate doses. The 3HB level may be a good predictor of the effectiveness of medication. Examination of serum 3HB levels may lead to earlier and more appropriate administration of sertraline and venlafaxine.
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Affiliation(s)
- Norihiro Saito
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, 036-8562, Japan
| | - Masamichi Itoga
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, 036-8562, Japan
| | - Satoko Minakawa
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, 036-8562, Japan
| | - Hiroyuki Kayaba
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, 036-8562, Japan
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15
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Hishida Y, Nakamura Y, Tsukiyama H, Nakagawa T, Sone M. A retrospective cohort study for the treatment of Asian diabetic ketoacidosis: optimizing initial doses of insulin. Acute Med Surg 2021; 8:e721. [PMID: 34976402 PMCID: PMC8705869 DOI: 10.1002/ams2.721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/25/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
Aim An insulin dose of 0.1 U/kg/h recommended by Western guidelines occasionally induces a precipitous decreasing blood glucose in Asian diabetic ketoacidosis (DKA). It is known that clinical factors, such as insulin sensitivity, differ between Asians and Americans/Europeans. We investigated how treatment options affect the time to DKA resolution to determine the optimal treatment for Asian DKA patients. Methods This was a retrospective cohort study from a single institution in Japan. A total of 34 adult DKA patients were observed. Baseline characteristics and treatment‐related parameters were compared between patients whose DKA was resolved within 18 h and those in which it was not. Results Significant differences were observed in the initial insulin dose (mean [standard deviation]: 0.053 [0.021] versus 0.031 [0.014] U/kg/h; P = 0.003) and the baseline β‐hydroxybutyrate (7.2 [3.2] versus 9.9 [2.6] mmol/L; P = 0.024) and HCO3− levels (11.2 [4.1] versus 7.7 [3.1] mmol/L; P = 0.014). Multivariable logistic regression analysis revealed that the initial insulin dose was significantly associated with early resolution of DKA and was independent of basal conditions. Receiver operating characteristic curve analysis indicated that the optimal cut‐off point for the initial insulin dose was 0.051 U/kg/h. With an initial insulin dose of 0.051 U/kg/h or higher, early resolution of DKA was obtained in 92.9% of patients. Conclusion An initial insulin dose of more than 0.05 U/kg/h provides an early resolution of DKA in Asian patients. Lower insulin doses significantly delay resolution. These results provide practical information for acute phase treatment of Asian DKA.
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Affiliation(s)
- Yoshiaki Hishida
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Yuta Nakamura
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hidekazu Tsukiyama
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Tomoko Nakagawa
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
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Lapolla A, Amaro F, Bruttomesso D, Di Bartolo P, Grassi G, Maffeis C, Purrello F, Tumini S. Diabetic ketoacidosis: A consensus statement of the Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology and Pediatric Diabetoloy (SIEDP). Nutr Metab Cardiovasc Dis 2020; 30:1633-1644. [PMID: 32771260 DOI: 10.1016/j.numecd.2020.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Diabetic ketoacidosis (DKA) is a serious medical emergency once considered typical of type 1 diabetes (T1DM), but now reported to occur in type 2 and GDM patients as well. DKA can cause severe complications and even prove fatal. The aim of our study was to review recent international and national guidelines on diagnosis, clinical presentation and treatment of diabetic ketoacidosis, to provide practical clinical recommendations. METHODS AND RESULTS Electronic databases (MEDLINE (via PUB Med), Scopus, Cochrane library were searched for relevant literature. Most international and national guidelines indicate the same accurate flow chart to diagnose, to evaluate from clinical and laboratory point of view, and treat diabetic ketoacidosis. CONCLUSION Prompt diagnosis, rapid execution of laboratory analysis and correct treatment are imperative to reduce the mortality related to diabetic ketoacidosis. These recommendations are designed to help healthcare professionals reduce the frequency and burden of DKA.
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Affiliation(s)
| | - Flavia Amaro
- Department of Pediatrics University of Chieti, Chieti, Italy
| | | | - Paolo Di Bartolo
- Ravenna Diabetes Clinic, Romagna Diabetes Network, Internal DPT of Romagna Local Health Autorithy, Italy; Chief Italian Association of Diabetologists (AMD), Rome, Italy
| | - Giorgio Grassi
- Endocrinology, Diabetology and Metabolic Unit, City of Health and Science Torino, Italy
| | - Claudio Maffeis
- Chief Italian Society of Pediatric Endocrinology and Diabetology (SIEDP), Torino, Italy; Chief Pediatric Diabetes and Metabolic Disorder Unit, University Hospital, Verona, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania Catania, Italy; Chief Italian Diabetes Society (SID), Rome, Italy
| | - Stefano Tumini
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Chieti Hospital, Chieti, Italy
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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18
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von Oettingen JE, Rhodes ET, Wolfsdorf JI. Resolution of ketoacidosis in children with new onset diabetes: Evaluation of various definitions. Diabetes Res Clin Pract 2018; 135:76-84. [PMID: 29111277 PMCID: PMC6013285 DOI: 10.1016/j.diabres.2017.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/22/2017] [Accepted: 09/18/2017] [Indexed: 01/21/2023]
Abstract
AIMS Data are sparse concerning use of serum electrolyte parameters as compared to venous blood gas (VBG) measurements to monitor acid-base status during treatment of diabetic ketoacidosis (DKA). We explored the utility of various parameters to define DKA resolution by investigating the relationship of venous pH (vpH), anion gap (AG), serum bicarbonate (HCO3), and glucose concentration during management of DKA in children with new onset diabetes mellitus (NODM). METHODS We included all patients with NODM presenting with DKA to Boston Children's Hospital from 10/1/07-7/1/13. DKA was defined as serum glucose ≥ 200 mg/dL (11.1 mmol/L) and vpH<7.30; severity as mild <7.30, moderate<7.20, severe<7.10; resolution of DKA as vpH≥7.30 and AG≤18 mmol/L. We used Cox regression to determine time to DKA resolution, and logistic regression to evaluate different serum HCO3 cut-off values as predictors of DKA resolution. RESULTS 263 patients (133F, mean age 9.9±4.4 years, 74% White) were included. DKA was mild in 134 (51%), moderate in 75 (28%) and severe in 54 (20%). In mild DKA, AG closed after normalization of vpH; in moderate and severe DKA, AG closed before normalization of vpH. HCO3>15mmol/L correlated with vpH≥7.30, and had 76% sensitivity and 85% specificity to predict DKA resolution. Median times to DKA resolution were similar using two different definitions: vpH and AG (8.4h [IQR 6.3-11.9]) vs. HCO3>15 mmol/L (7.9 h [IQR 5.0-11.8]), p=.42. CONCLUSIONS During management of pediatric DKA, HCO3 > 15 mmol/L reliably predicts resolution of DKA. In low-resource settings where VBG is unavailable, electrolyte parameters alone may be used to determine DKA resolution.
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Affiliation(s)
- Julia E von Oettingen
- Division of Endocrinology, Montreal Children's Hospital, McGill University Health Center, Montreal, QC H4A3J1, Canada; Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA.
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
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Abstract
Endocrinology relies on hormone and metabolite measurement for public health screening, diagnostics, and disease management. Advances in microfluidics, immunoassay technology, electronics, and software are moving in vitro endocrine diagnostics from the laboratory to the point of care. Point-of-care endocrine diagnostics provide results clinically equivalent to those produced by expensive laboratory instrumentation for a fraction of the cost and with a substantially more rapid turnaround time. Similar to the transformation of mainframe computers into laptops, tablets, and smartphones, clinical laboratories are evolving into point-of-care technologies.
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Affiliation(s)
- Joel Ehrenkranz
- i-calQ LLC, 466 North Wall Street, Salt Lake City, UT 84103, USA; Division of Endocrinology, Department of Medicine, University of Colorado School of Medicine, 13001 East 17th Place, Aurora, CO 80045, USA.
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20
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Cardoso L, Vicente N, Rodrigues D, Gomes L, Carrilho F. Controversies in the management of hyperglycaemic emergencies in adults with diabetes. Metabolism 2017; 68:43-54. [PMID: 28183452 DOI: 10.1016/j.metabol.2016.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/15/2016] [Accepted: 11/22/2016] [Indexed: 01/22/2023]
Abstract
Hyperglycaemic emergencies are associated with significant morbi-mortality and healthcare costs. Management consists on fluid replacement, insulin therapy, and electrolyte correction. However, some areas of patient management remain debatable. In patients without respiratory failure or haemodynamic instability, arterial and venous pH and bicarbonate measurements are comparable. Fluid choice varies upon replenishment phase and patient's condition. If patient is severely hypovolaemic, normal saline solution should be the first option. However, if patient has mild/moderate dehydration, fluid choice must take in consideration sodium concentration. Insulin therapy should be guided by β-hydroxybutyrate normalization and not by blood glucose. Variations of conventional insulin infusion protocols emerged recently. Priming dose of insulin may not be required, and fixed rate insulin infusion represents the best option to suppress hepatic glucose production, ketogenesis, and lipolysis. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycaemia. Simpler protocols using subcutaneous rapid-acting insulin analogues for mild/moderate diabetic ketoacidosis treatment have proven to be safe and effective, but further studies are required to confirm these results. Treatment with bicarbonate, phosphate, and low-molecular-weight heparin is still disputable, and randomized controlled trials are urgently needed to optimize patient management and decrease the morbi-mortality of hyperglycaemic emergencies.
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Affiliation(s)
- Luís Cardoso
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Nuno Vicente
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Dírcea Rodrigues
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Leonor Gomes
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Francisco Carrilho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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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.
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Affiliation(s)
- Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK
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22
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Brooke J, Stiell M, Ojo O. Evaluation of the Accuracy of Capillary Hydroxybutyrate Measurement Compared with Other Measurements in the Diagnosis of Diabetic Ketoacidosis: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13090837. [PMID: 27563914 PMCID: PMC5036670 DOI: 10.3390/ijerph13090837] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 08/13/2016] [Accepted: 08/17/2016] [Indexed: 12/02/2022]
Abstract
A complication of diabetes is diabetic ketoacidosis (DKA), which if left untreated is a life threatening condition. Prompt and accurate diagnosis of DKA is required for the commencement of life saving interventions. Measurements of ketone bodies in DKA have usually been through nitroprusside urine acetoacetate testing. The aim of this systematic review was to examine whether capillary β-hydroxybutyrate (β-OHB) testing is more accurate compared to other diagnostic methods of DKA. The following electronic databases were searched: EBSCO Host, MEDLINE, PSYCHInfo, CINAHL and Science Direct for publications from 1 January 2005 and up to and including 1 January 2016. Inclusion criteria were: Adults 18 years and over and known type 1 or type 2 diabetes. Retrospective and prospective observation studies were included. A total of nine studies met the inclusion criteria. Capillary β-OHB was found to have high sensitivity, specificity, positive predictive value and negative predictive value in identifying DKA compared to urinary ketone testing.
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Affiliation(s)
- Joanne Brooke
- College of Nursing, Midwifery and Healthcare, University of West London, Boston Manor Road Brentford, Middlesex TW8 9GA, UK.
| | - Marlon Stiell
- Faculty of Education and Health, University of Greenwich, Avery Hill Campus, London SE9 2UG, UK.
| | - Omorogieva Ojo
- Faculty of Education and Health, University of Greenwich, Avery Hill Campus, London SE9 2UG, UK.
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23
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Gorman L, Sharkey LC, Armstrong PJ, Little K, Rendahl A. Serum Beta Hydroxybutyrate Concentrations in Cats with Chronic Kidney Disease, Hyperthyroidism, or Hepatic Lipidosis. J Vet Intern Med 2016; 30:611-6. [PMID: 26773702 PMCID: PMC4913593 DOI: 10.1111/jvim.13826] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/30/2015] [Accepted: 12/14/2015] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Ketones, including beta hydroxybutyrate (BHB), are produced in conditions of negative energy balance and decreased glucose utilization. Serum BHB concentrations in cats are poorly characterized in diseases other than diabetes mellitus. HYPOTHESIS Serum BHB concentrations will be increased in cats with chronic kidney disease (CKD), hyperthyroidism (HT), or hepatic lipidosis (HL). ANIMALS Twenty-eight client-owned cats with CKD, 34 cats with HT, and 15 cats with HL; 43 healthy cats. METHODS Prospective observational study. Serum BHB concentrations were measured at admission in cats with CKD, HT, and HL, for comparison with a reference interval established using healthy cats. Results of dipstick urine ketone measurement, when available, were compared to BHB measurement. RESULTS Beta hydroxybutyrate was above the reference interval (<0.11 mmol/L) in 6/28 cats (21%) with CKD, 7/34 cats (20%) with HT, and 11/15 cats (73%) with HL, significantly exceeding the expected 2.5% above the reference interval for healthy cats (P < .001 for all groups). Elevations were mild in CKD and HT groups (median BHB 0.1 mmol/L for both groups, 80th percentile 0.12 and 0.11 mmol/L, respectively), but more marked in HL cats (median BHB 0.2 mmol/L, 80th percentile 0.84 mmol/L). None of 11 cats with increased serum BHB concentration having urine dipstick analysis performed within 24 h of sampling for BHB were ketonuric. CONCLUSIONS AND CLINICAL IMPORTANCE Increases in serum BHB concentrations occur in cats with CKD, HT, and HL, and might provide an useful index of catabolism.
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Affiliation(s)
- L Gorman
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN
| | - L C Sharkey
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN
| | - P J Armstrong
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN
| | - K Little
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN
| | - A Rendahl
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN
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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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25
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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.
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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
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Pichler M, Damberger A, Arnholdt T, Schwendenwein I, Gasteiner J, Drillich M, Iwersen M. Evaluation of 2 electronic handheld devices for diagnosis of ketonemia and glycemia in dairy goats. J Dairy Sci 2014; 97:7538-46. [PMID: 25282414 DOI: 10.3168/jds.2014-8198] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 08/15/2014] [Indexed: 11/19/2022]
Abstract
The objective of this study was to evaluate the suitability of the electronic handheld devices FreeStyle Precision (FSP; Abbott Germany, Wiesbaden, Germany) and GlucoMen LX Plus (GML; A. Menarini GmbH, Vienna, Austria) for the measurement of β-hydroxybutyrate (BHBA) in whole blood in dairy goats. Additionally, glucose concentration was analyzed with the FSP device. For method comparison, the samples were also analyzed in the laboratory by standard methods, which served as the gold standard in our study. A further objective was to evaluate the agreement between samples obtained by minimal invasive venipuncture of an ear vein and measurements of whole blood samples from the jugular vein (vena jugularis). In total, 173 blood sample pairs collected from 28 goats were obtained from an ear vein and from the jugular vein. The Spearman correlation coefficients (rsp) for BHBA concentrations determined with the FSP or GML and the gold standard were 0.95 and 0.85 for the ear vein and 0.98 and 0.88 for the jugular vein, respectively. Bland-Altman plots of differences showed a positive bias of 0.12 (ear vein) and 0.21 (jugular vein) when determination was performed with the FSP and a negative bias of 0.21 (ear vein) and 0.24 (jugular vein) when using the GML. For the FSP, applying the adjusted thresholds determined by ROC analysis of 0.9 (ear vein) and 1.0 mmol/L (jugular vein) allowed to distinguish between healthy goats and animals with hyperketonemia with sensitivities (Se) and specificities (Sp) for samples from the ear vein of 0.98 and 0.85, and from the jugular vein of 0.99 and 0.94, respectively. For the GML, adjusted thresholds were 0.5 mmol/L for the ear vein (Se=0.94, Sp=0.75) and 0.6 mmol/L for the jugular vein (Se=0.88, Sp=0.91). Repeated analyses of defined whole blood samples showed average inter- and intraassay coefficients of variation of 6.6 and 7.3% for FSP, and of 35.6 and 35.4% for GML, respectively. Test characteristics for determining glucose concentration with the FSP compared with the gold standard were poor (ear vein: rsp=0.41; jugular vein: rsp=0.51), with low validity to distinguish between hypo- and normoglycemia (Se=0.71, Sp=0.66). The present study showed good test characteristics for the FSP and moderate for the GML device for determining BHBA concentrations in whole blood. Additionally the results demonstrate the suitability of testing BHBA concentration in a blood drop obtained from an ear vein. Based on the results of this study, the FSP device is not suitable to differentiate normo- from hypoglycemia in goats.
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Affiliation(s)
- M Pichler
- University Clinic for Ruminants, Clinical Unit for Herd Health Management in Ruminants, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, 1210 Vienna, Austria
| | - A Damberger
- University Clinic for Ruminants, Clinical Unit for Herd Health Management in Ruminants, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, 1210 Vienna, Austria
| | - T Arnholdt
- University Clinic for Ruminants, Clinical Unit for Herd Health Management in Ruminants, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, 1210 Vienna, Austria
| | - I Schwendenwein
- Central Clinical Pathology Unit, Department for Pathobiology, University of Veterinary Medicine Vienna, 1210 Vienna, Austria
| | - J Gasteiner
- Agricultural Research and Education Center Raumberg-Gumpenstein, 8952 Irdning, Styria, Austria
| | - M Drillich
- University Clinic for Ruminants, Clinical Unit for Herd Health Management in Ruminants, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, 1210 Vienna, Austria
| | - M Iwersen
- University Clinic for Ruminants, Clinical Unit for Herd Health Management in Ruminants, Department for Farm Animals and Veterinary Public Health, University of Veterinary Medicine Vienna, 1210 Vienna, Austria.
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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Koves IH, Leu MG, Spencer S, Popalisky JC, Drummond K, Beardsley E, Klee K, Zimmerman JJ. Improving care for pediatric diabetic ketoacidosis. Pediatrics 2014; 134:e848-56. [PMID: 25092935 DOI: 10.1542/peds.2013-3764] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures. METHODS Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets. RESULTS Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations. CONCLUSIONS Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities.
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Affiliation(s)
| | | | | | | | | | | | | | - Jerry J Zimmerman
- Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington
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Wolfsdorf JI. The International Society of Pediatric and Adolescent Diabetes guidelines for management of diabetic ketoacidosis: Do the guidelines need to be modified? Pediatr Diabetes 2014; 15:277-86. [PMID: 24866064 DOI: 10.1111/pedi.12154] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 04/18/2014] [Indexed: 12/15/2022] Open
Abstract
The current version of the International Society of Pediatric and Adolescent Diabetes (ISPAD) guidelines for management of diabetic ketoacidosis (DKA) is largely based on the Lawson Wilkins Pediatric Endocrine Society/European Society of Pediatric Endocrinology (LWPES/ESPE) consensus statement on DKA in children and adolescents published in 2004. This article critically reviews and presents the most pertinent new data published in the past decade, which have implications for diagnosis and management. Four elements of the guidelines warrant modification: (i) The definition of DKA; (ii) insulin therapy; (iii) water and salt replacement; and (iv) blood ß-hydroxybutyrate measurements for the management of DKA.
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Affiliation(s)
- Joseph I Wolfsdorf
- Diabetes Program, Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Bresciani F, Pietra M, Corradini S, Giunti M, Fracassi F. Accuracy of capillary blood 3-β-hydroxybutyrate determination for the detection and treatment of canine diabetic ketoacidosis. J Vet Sci 2014; 15:309-16. [PMID: 24675829 PMCID: PMC4087234 DOI: 10.4142/jvs.2014.15.2.309] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 02/21/2014] [Indexed: 11/20/2022] Open
Abstract
In human medicine, diagnosis of diabetic ketoacidosis (DKA) is usually based on measurement of capillary 3-β-hydroxybutyrate (3-HB) with a hand held ketone sensor. This study was conducted to determine if measurement of capillary 3-HB could be useful for the diagnosis and monitoring of canine DKA. Fifteen dogs with diabetic ketosis and 10 with DKA were evaluated. Paired measurements of 3-HB of capillary and venous blood samples were analysed by the electrochemical sensor and reference method. Use of capillary 3-HB measurement during DKA management was then evaluated through simultaneous measurements of capillary 3-HB, urinary AcAc and venous blood gas analysis. Good agreement between capillary and venous 3-HB measurement was detected by the electrochemical sensor and reference method. Monitoring treatment of DKA revealed a significant correlation between capillary 3-HB and acidosis markers, while no significant correlation was observed between AcAc and acidosis markers. A cut-off value of capillary blood 3-HB >3.8 mmol/L for diagnosis of DKA resulted in 70% and 92% sensitivity and specificity. The electrochemical sensor accurately measures 3-HB concentration in both capillary and venous blood samples, is accurate in diagnosing canine DKA, and appears to reflect the patient's metabolic status during DKA treatment.
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Affiliation(s)
- Francesca Bresciani
- Department of Veterinary Medical Sciences, University of Bologna, 40126 Bologna, Italy
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Abstract
Despite many advances, the incidence of pediatric-onset diabetes and diabetic ketoacidosis (DKA) is increasing. Diabetes mellitus is 1 of the most common chronic pediatric illnesses and, along with DKA, is associated with significant cost and morbidity. DKA is a complicated metabolic state hallmarked by dehydration and electrolyte disturbances. Treatment involves fluid resuscitation with insulin and electrolyte replacement under constant monitoring for cerebral edema. When DKA is recognized and treated immediately, the prognosis is excellent. However, when a patient has prolonged or multiple courses of DKA or if DKA is complicated by cerebral edema, the results can be devastating.
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Affiliation(s)
- Laura Olivieri
- Department of Emergency Medicine, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
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Klocker AA, Phelan H, Twigg SM, Craig ME. Blood β-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: a systematic review. Diabet Med 2013; 30:818-24. [PMID: 23330615 DOI: 10.1111/dme.12136] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 11/02/2012] [Accepted: 01/15/2013] [Indexed: 11/29/2022]
Abstract
AIM Diabetic ketoacidosis is a life-threatening complication of Type 1 diabetes. Blood β-hydroxybutyrate testing is now widely available as an alternative to urine acetoacetate testing for detecting ketosis. The aim of this study was to review the effectiveness of capillary or serum β-hydroxybutyrate compared with urine acetoacetate testing in prevention and management of diabetic ketoacidosis. METHODS MEDLINE, EMBASE, EBM Reviews, The Cochrane Library and CINAHL (until April 2012, no language restrictions, studies in humans) were searched for experimental and observational studies comparing the effectiveness of blood β-hydroxybutyrate and urine acetoacetate testing. Outcomes examined were prevention of diabetic ketoacidosis, time to recovery from diabetic ketoacidosis, healthcare costs and patient or caregiver satisfaction. Additional sources included reference lists, conference proceedings and contact with experts in the field. RESULTS Four studies (two randomized controlled trials and two cohort studies) met eligibility criteria, including 299 participants across 11 centres. Risk of bias was low to moderate. Blood ketone testing compared with urine testing was associated with reduced frequency of hospitalization (one study), reduced time to recovery from diabetic ketoacidosis (three studies), cost benefits (one study) and greater satisfaction (one study, intervention group only). No study assessed prevention of diabetic ketoacidosis. Meta-analysis could not be performed because of heterogeneity in study design and published data. CONCLUSIONS There is evidence suggesting that blood β-hydroxybutyrate testing is more effective than urine acetoacetate testing in reducing emergency department assessment, hospitalization and time to recovery from diabetic ketoacidosis, as well as potentially lowering healthcare expenditure. Further research in both young people and adults is needed.
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Affiliation(s)
- A A Klocker
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
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Koves IH, Pihoker C. Pediatric diabetic ketoacidosis management in the era of standardization. Expert Rev Endocrinol Metab 2012; 7:433-443. [PMID: 30754163 DOI: 10.1586/eem.12.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Up to 70% of children with new-onset Type 1 diabetes mellitus (T1DM) present with diabetic ketoacidosis (DKA), with most cases initially assessed by their primary care provider. DKA is the most common cause of death in children with T1DM, mainly related to cerebral edema that occurs at a frequency of 0.15-4.6%. Early recognition of DKA can be improved by increasing the awareness of early clinical symptoms such as enuresis, polyuria and polydipsia. Clinical acumen paired with early assessment of patients with suspected T1DM and known T1DM, particularly if risk factors for DKA are present, can prevent serious complications and fatal outcomes. Urgent referral to specialist centers for suspected new-onset T1DM/DKA is required. A standardized approach is recommended to be followed to ensure successful initial management of DKA, both in the nonspecialist setting before transfer and in the more specialized hospital setting. This article outlines such a management approach.
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Affiliation(s)
- Ildiko H Koves
- b Seattle Children's Hospital, Division of Endocrinology and Diabetes, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| | - Catherine Pihoker
- a Seattle Children's Hospital, Division of Endocrinology and Diabetes, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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Panousis N, Brozos C, Karagiannis I, Giadinis ND, Lafi S, Kritsepi-Konstantinou M. Evaluation of Precision Xceed® meter for on-site monitoring of blood β-hydroxybutyric acid and glucose concentrations in dairy sheep. Res Vet Sci 2011; 93:435-9. [PMID: 21764413 DOI: 10.1016/j.rvsc.2011.06.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 06/16/2011] [Accepted: 06/22/2011] [Indexed: 11/25/2022]
Abstract
The accuracy of the Precision Xceed® hand-held meter as an on-site method for measuring blood β-hydroxybutyric acid (BHBA) and glucose concentrations, for the diagnosis of pregnancy toxemia and ketosis in dry and lactating dairy sheep, was assessed. Five to eight hours after the start of the morning feed, blood was collected once from 193 clinically healthy sheep (143 dry and 50 lactating). BHBA and glucose analyses were performed with serum in the laboratory, and with whole blood with the Precision Xceed®. Overall, BHBA and glucose determinations by the two methods were not statistically different (P>0.05). Strongly significant positive correlations were found for glucose and BHBA concentrations between the Precision Xceed® and laboratory results (r=0.76, n=150, P<0.01 and r=0.99, n=193, P<0.01, respectively). The Precision Xceed® was highly sensitive (98.6%) and specific (98.2%), and had excellent test agreement for the detection of pregnancy toxemia and ketosis.
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Affiliation(s)
- N Panousis
- Clinic of Farm Animals, Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece.
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, Lernmark A, Metzger BE, Nathan DM. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care 2011; 34:e61-99. [PMID: 21617108 PMCID: PMC3114322 DOI: 10.2337/dc11-9998] [Citation(s) in RCA: 316] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 02/28/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these tests varies substantially. APPROACH An expert committee compiled evidence-based recommendations for the use of laboratory testing for patients with diabetes. A new system was developed to grade the overall quality of the evidence and the strength of the recommendations. Draft guidelines were posted on the Internet and presented at the 2007 Arnold O. Beckman Conference. The document was modified in response to oral and written comments, and a revised draft was posted in 2010 and again modified in response to written comments. The National Academy of Clinical Biochemistry and the Evidence-Based Laboratory Medicine Committee of the American Association for Clinical Chemistry jointly reviewed the guidelines, which were accepted after revisions by the Professional Practice Committee and subsequently approved by the Executive Committee of the American Diabetes Association. CONTENT In addition to long-standing criteria based on measurement of plasma glucose, diabetes can be diagnosed by demonstrating increased blood hemoglobin A(1c) (HbA(1c)) concentrations. Monitoring of glycemic control is performed by self-monitoring of plasma or blood glucose with meters and by laboratory analysis of HbA(1c). The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed. SUMMARY The guidelines provide specific recommendations that are based on published data or derived from expert consensus. Several analytes have minimal clinical value at present, and their measurement is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, USA.
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, Lernmark A, Metzger BE, Nathan DM. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem 2011; 57:e1-e47. [PMID: 21617152 DOI: 10.1373/clinchem.2010.161596] [Citation(s) in RCA: 300] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these tests varies substantially. APPROACH An expert committee compiled evidence-based recommendations for the use of laboratory testing for patients with diabetes. A new system was developed to grade the overall quality of the evidence and the strength of the recommendations. Draft guidelines were posted on the Internet and presented at the 2007 Arnold O. Beckman Conference. The document was modified in response to oral and written comments, and a revised draft was posted in 2010 and again modified in response to written comments. The National Academy of Clinical Biochemistry and the Evidence Based Laboratory Medicine Committee of the AACC jointly reviewed the guidelines, which were accepted after revisions by the Professional Practice Committee and subsequently approved by the Executive Committee of the American Diabetes Association. CONTENT In addition to long-standing criteria based on measurement of plasma glucose, diabetes can be diagnosed by demonstrating increased blood hemoglobin A(1c) (Hb A(1c)) concentrations. Monitoring of glycemic control is performed by self-monitoring of plasma or blood glucose with meters and by laboratory analysis of Hb A(1c). The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed. SUMMARY The guidelines provide specific recommendations that are based on published data or derived from expert consensus. Several analytes have minimal clinical value at present, and their measurement is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD 20892-1508, USA.
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Abstract
Diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus (DM), occurs more commonly in children with type 1 DM than type 2 DM. Hyperglycemia, metabolic acidosis, ketonemia, dehydration and various electrolyte abnormalities result from a relative or absolute deficiency of insulin with or without an excess of counter-regulatory hormones. Management requires careful replacement of fluid and electrolyte deficits, intravenous administration of insulin, and close monitoring of clinical and biochemical parameters directed towards timely detection of complications, including hypokalemia, hypoglycemia and cerebral edema. Cerebral edema may be life threatening and is managed with fluid restriction, administration of mannitol and ventilatory support as required. Factors precipitating the episode of DKA should be identified and rectified. Following resolution of ketoacidosis, intravenous insulin is transitioned to subcutaneous route, titrating dose to achieve normoglycemia.
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Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med 2011; 12:137-40. [PMID: 20473242 DOI: 10.1097/pcc.0b013e3181e2a21b] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare the effects of infusing insulin at 0.05 units/kg/hr rather than 0.1 units/kg/hr in children admitted to the intensive care unit with diabetic ketoacidosis. DESIGN A retrospective observational study. SETTING A tertiary pediatric intensive care unit. PATIENTS All children with diabetic ketoacidosis admitted during the 6-yr period from 2000 to 2005. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The effective plasma osmolality (plasma glucose concentration in mmol/L + twice the plasma sodium concentration in mmol/L), plasma glucose, plasma sodium, fluid intake, and acid-base status 12 hrs after the commencement of the insulin infusion. Compared to the 34 children who received 0.1 units/kg/hr of insulin, the 33 children who received 0.05 units/kg/hr of insulin were younger (median age, 25 mos vs. 62 mos, p = .024) and had a more gradual reduction in the effective plasma osmolality over the first 12 hrs (p < .0005); this was because plasma glucose decreased more slowly (p = .004) and plasma sodium increased faster (p < .0005). Both groups had a satisfactory improvement in acidosis and ketosis, and they had a similar length of stay in the intensive care unit. CONCLUSIONS Further studies are needed to evaluate the role of using 0.05 units/kg/hr of insulin to treat children with diabetic ketoacidosis. The smaller dose of insulin may make it easier to lower the effective plasma osmolality gradually and might, therefore, reduce the risk of cerebral edema.
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Voyvoda H, Erdogan H. Use of a hand-held meter for detecting subclinical ketosis in dairy cows. Res Vet Sci 2010; 89:344-51. [DOI: 10.1016/j.rvsc.2010.04.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Revised: 01/11/2010] [Accepted: 04/05/2010] [Indexed: 11/26/2022]
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Puttha R, Cooke D, Subbarayan A, Odeka E, Ariyawansa I, Bone M, Doughty I, Patel L, Amin R. Low dose (0.05 units/kg/h) is comparable with standard dose (0.1 units/kg/h) intravenous insulin infusion for the initial treatment of diabetic ketoacidosis in children with type 1 diabetes-an observational study. Pediatr Diabetes 2010; 11:12-7. [PMID: 19602154 DOI: 10.1111/j.1399-5448.2009.00536.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To compare low dose (0.05 units/kg/h) with standard dose (0.1 units/kg/h) intravenous insulin infusion for the treatment of diabetic ketoacidosis (DKA) in children with type 1 diabetes. STUDY DESIGN Data from five paediatric centres were compared in children who received 0.05 (41 episodes) or 0.1 units/kg/h (52 episodes). RESULTS In the low vs. standard dose group, at 6 h following admission, the fall in blood glucose levels [11.3 (95% confidence interval 8.6 to 13.9) vs. 11.8 (8.4 to 15.2) mmol/L, p = 0.86] and rise in pH [0.13 (0.09 to 0.18) vs. 0.11 (0.07 to 0.15), p = 0.78] were similar. These changes were comparable between doses in relation to: severity of initial acidosis, children newly diagnosed with diabetes or aged less than 5 years. After adjustment for other clinical and biochemical covariates, insulin dose was unrelated to the change in pH and blood glucose levels at 6 h following admission. Comparisons of safety data, particularly in relation to abnormal Glasgow Coma Score, were inconclusive. CONCLUSION In this observational study, low dose was as effective as standard dose intravenous insulin infusion in the initial treatment (less than 6 h) of DKA in children with type 1 diabetes. A randomised controlled trial is required to show true equivalence between doses and to evaluate potential safety benefits.
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Affiliation(s)
- R Puttha
- Department of Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
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Cuerva Carvajal A, Villegas Portero R. [Ketone bodies test near patient: accuracy, effectiveness, utility and economic evaluation]. Med Clin (Barc) 2008; 131:435-6. [PMID: 18928726 DOI: 10.1157/13126232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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