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Gal A, Odunayo A. Diabetes Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome in Companion Animals. Vet Clin North Am Small Anim Pract 2023; 53:531-550. [PMID: 36898859 DOI: 10.1016/j.cvsm.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Diabetes mellitus is a common endocrinopathy in dogs and cats. Diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening complications of diabetes resulting from an imbalance between insulin and the glucose counter-regulatory hormones. The first part of this review focuses on the pathophysiology of DKA and HHS, and rarer complications such as euglycemic DKA and hyperosmolar DKA. The second part of this review focuses on the diagnosis and treatment of these complications.
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Affiliation(s)
- Arnon Gal
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, 1008 West Hazelwood Drive, Urbana, IL 61820, USA.
| | - Adesola Odunayo
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, 2015 Southwest 16th Avenue, Gainesville, FL 32608, USA
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Pierce KN, Lee S, Pacheco R, Sadar MJ. Hyperglycemic hyperosmolar syndrome in a domestic ferret (Mustela putorius furo) following a partial pancreatectomy. J Exot Pet Med 2020. [DOI: 10.1053/j.jepm.2020.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Buscaglia NA, Hanley CS. Hyperglycemic hyperosmolar state in a chimpanzee (Pan troglodytes). J Med Primatol 2020; 49:332-336. [PMID: 32542742 DOI: 10.1111/jmp.12480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 01/08/2023]
Abstract
A 19-year-old female chimpanzee (Pan troglodytes) presented for cachexia, acute weakness, hyporexia, icterus, and polyuria. The animal was diagnosed with a hyperglycemic hyperosmolar state, which is a well-recognized syndrome in diabetic humans that is rarely diagnosed in animals. This case documents an important and likely under-reported syndrome in non-human primates.
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Malerba E, Cattani C, Del Baldo F, Carotenuto G, Corradini S, Golinelli S, Drudi I, Fracassi F. Accuracy of a flash glucose monitoring system in dogs with diabetic ketoacidosis. J Vet Intern Med 2019; 34:83-91. [PMID: 31725202 PMCID: PMC6979271 DOI: 10.1111/jvim.15657] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 10/23/2019] [Indexed: 01/01/2023] Open
Abstract
Background A factory‐calibrated flash glucose monitoring system (FGMS; FreeStyle Libre) recently was evaluated in dogs with uncomplicated diabetes mellitus. It is not known if this system is reliable during diabetic ketoacidosis (DKA). Objectives To assess the performance of the FGMS in dogs with DKA and to determine the effect of severity of ketosis and acidosis, lactate concentration, body condition score (BCS), and time wearing the sensor on the accuracy of the device. Animals Fourteen client‐owned dogs with DKA. Methods The interstitial glucose (IG) measurements were compared with blood glucose (BG) measurements obtained using a validated portable glucometer. The influence of changes in metabolic variables (β‐hydroxybutyrate, pH, bicarbonate, and lactate) and the effect of BCS and time wearing on sensor performance were evaluated. Accuracy was determined by fulfillment of ISO15197:2013 criteria. Results Metabolic variables, BCS, and time wearing were not associated with the accuracy of the sensor. Good agreement between IG measurements and BG was obtained both before and after DKA resolution (r = .88 and r = .93, respectively). Analytical accuracy was not achieved, whereas clinical accuracy was demonstrated with 100% and 99.6% of results in zones A + B of the Parkes consensus error grid analysis before and after DKA resolution, respectively. Conclusions and Clinical Importance Changes in metabolic variables, BCS, and time wearing do not seem to affect agreement between IG and BG. Despite not fulfilling the ISO requirements, the FGMS provides clinically accurate estimates of BG in dogs with DKA.
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Affiliation(s)
- Eleonora Malerba
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Chiara Cattani
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Francesca Del Baldo
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Gaia Carotenuto
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Sara Corradini
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Stefania Golinelli
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
| | - Ignazio Drudi
- Department of Statistical Sciences, University of Bologna, Bologna, Italy
| | - Federico Fracassi
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Bologna, Italy
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Pereira N, Novo Matos J, Baron Toaldo M, Bartoszuk U, Summerfield N, Riederer A, Reusch C, Glaus T. Cats with diabetes mellitus have diastolic dysfunction in the absence of structural heart disease. Vet J 2017; 225:50-55. [DOI: 10.1016/j.tvjl.2017.04.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 04/27/2017] [Accepted: 04/28/2017] [Indexed: 12/15/2022]
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DiFazio J, Fletcher DJ. Retrospective comparison of early- versus late-insulin therapy regarding effect on time to resolution of diabetic ketosis and ketoacidosis in dogs and cats: 60 cases (2003-2013). J Vet Emerg Crit Care (San Antonio) 2015; 26:108-15. [PMID: 26551019 DOI: 10.1111/vec.12415] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 09/28/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether early insulin administration (≤6 h after admission) results in more rapid resolution of diabetic ketosis (DK) and ketoacidosis (DKA), shorter duration of hospitalization, and higher incidence of complications, and whether more severe ketonuria is associated with longer time to resolution of DK/DKA. DESIGN Retrospective study (January 1, 2003-March 1, 2013). SETTING University teaching hospital. ANIMALS Sixty dogs and cats with DK or DKA receiving short-acting insulin therapy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Medical records were reviewed and data recorded including signalment; previous history of diabetes; intake temperature, blood pressure, blood glucose, pH, base excess, and degree of ketonuria; time to short-acting insulin therapy and resolution of DK/DKA; length of hospitalization; and complications. Insulin was initiated ≤6 hours in the early group and >6 hours in the late group after hospital admission. Early group patients had more rapid resolution of DK/DKA after starting short-acting insulin therapy (36.4 ± 22.6 vs. 55.4 ± 26.6 h, P = 0.014). There was no difference in duration of hospitalization or complications. More severe ketonuria resulted in longer time to resolution of DK/DKA after initiation of short-acting insulin (severe: 50.9 ± 24.2; moderate: 29.6 ± 19; mild: 23.4 ± 21.9 h, P = 0.005, all individual pairwise comparisons P < 0.05). CONCLUSIONS Early insulin administration is associated with more rapid resolution of DK/DKA without an associated increase in complication rates. DK/DKA took longer to resolve with more severe ketonuria. Prospective studies are warranted to identify specific time targets for insulin administration in DK/DKA patients.
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Affiliation(s)
- Jillian DiFazio
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, 14853
| | - Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, 14853
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Trotman TK, Drobatz KJ, Hess RS. Retrospective evaluation of hyperosmolar hyperglycemia in 66 dogs (1993-2008). J Vet Emerg Crit Care (San Antonio) 2013; 23:557-64. [PMID: 24102960 DOI: 10.1111/vec.12100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 08/04/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To clinically characterize a large group of dogs with the hyperosmolar hyperglycemic state (HHS) and to determine whether 2 HHS subgroups, dogs with hyperosmolar ketonuric (HK) diabetes mellitus (DM) and dogs with hyperosmolar nonketonuric (HNK) DM were clinically different from one another. DESIGN Retrospective study. Records of 1,250 diabetic dogs that were examined between January 1993 and July 2008 were reviewed in order to identify dogs with HHS. Inclusion required a calculated serum osmolality ≥325 mOsm/kg, with or without ketonuria. SETTING University teaching hospital. ANIMALS Sixty-six dogs with HHS including 34 dogs with HK, 25 dogs with HNK, and 7 dogs with unclassified HHS. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS HHS was diagnosed in 5% of dogs with DM. HK and HNK dogs were similar to one another in regard to most historical, physical examination, and clinicopathologic variables as well as outcome. Sixty-two percent of dogs with HHS survived to discharge from the hospital. Poor outcome of HHS dogs was associated with abnormal mental status (P = 0.03) and a low venous pH (P = 0.045). Dogs with HK were significantly more likely to have acute pancreatitis (P = 0.046), higher body temperature (P = 0.006), higher WBC count (P = 0.01), and a shorter duration of clinical signs (P = 0.02) compared to dogs with HNK. Dogs with HNK had significantly higher BUN and creatinine concentrations (P = 0.0002 and P = 0.008, respectively) and higher calculated osmolality (P = 0.001) compared to dogs with HK. CONCLUSIONS HHS is a rare condition in which poor outcome is associated with abnormal mental status and low venous pH. Among dogs with HHS, the subgroup of dogs with HK has significantly more acute pancreatitis, shorter duration of clinical signs, and higher body temperature and WBC count compared to dogs with HNK, whereas dogs with HNK have more azotemia and higher calculated osmolality compared to dogs with HK.
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Affiliation(s)
- Tara K Trotman
- Department of Clinical Sciences, School of Veterinary Medicine, Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania, Philadelphia, PA, 19104
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Abstract
Success in treatment of endocrine emergencies is contingent on early recognition and treatment. Many endocrine diseases presenting emergently have nonspecific signs and symptoms. In addition, these endocrine crises are often precipitated by concurrent disease, further making early identification difficult. This article concentrates on recognition and emergency management of the most common endocrine crises in dogs and cats.
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Affiliation(s)
- Amie Koenig
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA.
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Marshall RD, Rand JS, Gunew MN, Menrath VH. Intramuscular glargine with or without concurrent subcutaneous administration for treatment of feline diabetic ketoacidosis. J Vet Emerg Crit Care (San Antonio) 2013; 23:286-90. [PMID: 23530935 DOI: 10.1111/vec.12038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 02/12/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To describe treatment response and outcome in 15 cats with diabetic ketoacidosis (DKA) initially stabilized with glargine administered intramuscularly (IM) with or without subcutaneous (SC) glargine. MATERIALS AND METHODS Fifteen cats diagnosed with DKA were initially administered IM glargine (1-2 U) and in most cats (12/15 cats) this was combined with SC glargine (1-3 U). This was followed by intermittent IM glargine as required at intervals of 2 or more hours (range 2-22 h) and SC glargine (1-2 U) every 12 hours. KEY FINDINGS All 15 cats survived and were discharged from hospital (median 4 d; range 2-5 d) and one-third (5/15) of cats subsequently achieved remission (median time 20 d; range 15-29 d). Complications included hypokalemia and hypophosphatemia, which were likely the result of DKA therapy rather than glargine treatment specifically. SIGNIFICANCE This study demonstrates that glargine administered IM is an effective treatment for DKA in cats, and may provide an alternative to regular insulin. The same vial used for initial treatment of DKA can then be used for subsequent management with SC glargine injections. Future prospective randomized controlled trials evaluating clinical outcomes in cats with DKA using different types and routes of administration of insulin are warranted. A prospective randomized controlled trial is required to compare outcomes for IM and IV administration of glargine and regular insulin in DKA cats with or without SC glargine.
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Affiliation(s)
- Rhett D Marshall
- Centre for Companion Animal Health, School of Veterinary Science, The University of Queensland, QLD, 4072, Australia
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Rand JS. Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State in Cats. Vet Clin North Am Small Anim Pract 2013; 43:367-79. [DOI: 10.1016/j.cvsm.2013.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Bloom CA, Rand JS. Diabetes and the Kidney in Human and Veterinary Medicine. Vet Clin North Am Small Anim Pract 2013; 43:351-65. [DOI: 10.1016/j.cvsm.2012.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Murphy K, Hibbert A. The flat cat: 2. the emergency database and management of common metabolic abnormalities. J Feline Med Surg 2013; 15:189-99. [PMID: 23422363 DOI: 10.1177/1098612x13477539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM Detailed information regarding the causes and treatment of acute collapse in the cat can be difficult to locate in a single published source. This two-part review aims to provide a logical approach to the clinical assessment and stabilisation of the critically ill collapsed cat. PRACTICAL RELEVANCE Laboratory evaluation, in the form of an emergency database, is an important part of the initial assessment of a collapsed patient and should be considered in conjunction with physical abnormalities. CLINICAL CHALLENGES Rapid identification and correction of life-threatening metabolic abnormalities, including hypoglycaemia, hypocalcaemia and hyperkalaemia, is essential in stabilising this group of patients. Clinicians often lack confidence if they are not dealing with these problems regularly. AUDIENCE The information provided in this article will be of use to any veterinarian working with feline patients and particularly those dealing with emergencies on a regular basis. EVIDENCE BASE There is an extensive body of published literature, both original studies and textbook chapters, pertaining to the causes and treatment of the important metabolic abnormalities covered in this article. The authors draw on information from original articles, reviews and their clinical experience to provide simple but detailed practical information to guide interpretation of the emergency database and its application to therapy in the emergency setting.
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Affiliation(s)
- Kate Murphy
- Bath Veterinary Referrals, Rosemary Lodge, Wellsway, Bath BA2 5RL, UK.
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Abstract
Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome are two serious and potentially life-threatening complications of diabetes mellitus. Understanding pathophysiology is crucial to the proper management of veterinary patients with these disorders. This article reviews the biochemical alterations contributing to these conditions, and discusses traditional and controversial management strategies.
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Affiliation(s)
- Mauria A O'Brien
- Department of Veterinary Clinical Medicine, University of Illinois at Urbana-Champaign, 1008 West Hazelwood Drive, Urbana, IL 61802, USA.
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Zeugswetter F, Pagitz M. Ketone measurements using dipstick methodology in cats with diabetes mellitus. J Small Anim Pract 2008; 50:4-8. [PMID: 19037889 DOI: 10.1111/j.1748-5827.2008.00657.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the results of urine and plasma ketone dip test in a group of diabetic cats with possible ketosis or ketoacidosis, using laboratory plasma beta-hydroxybutyrate measurements as the gold standard. METHODS According to clinical examinations, plasma beta-hydroxybutyrate measurements and venous blood gas analysis, 54 cats with diabetes mellitus were classified as non-ketotic (n=3), ketotic (n=40) or ketoacidotic (n=11). Plasma and urine acetoacetate concentrations were determined using urine reagent strips. RESULTS Although there was a significant positive correlation between blood and urine ketone measurements (r=0.695, P<0.001), the results differed significantly (Z=-3.494, P<0.001). Using the differential positive rates, the best cut-off value to detect cats with ketoacidosis was 1.5 mmol/l for urine and 4 mmol/l for plasma. The sensitivity/specificity was 82/95 per cent for urine and 100/88 per cent for plasma, respectively. CLINICAL SIGNIFICANCE The urine and plasma ketone dip tests have a different diagnostic accuracy, and results have to be interpreted differently. Because of its high sensitivity, the plasma ketone dip test performs better than the urine ketone dip test to identify cats with impending or established ketoacidosis.
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Affiliation(s)
- F Zeugswetter
- Clinical Department of Small Animals and Horses, University of Veterinary Medicine, Veterinärplatz 1, A-1210 Vienna
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Fluid and Electrolyte Therapy in Endocrine Disorders: Diabetes Mellitus and Hypoadrenocorticism. Vet Clin North Am Small Anim Pract 2008; 38:699-717, xiii-xiv. [DOI: 10.1016/j.cvsm.2008.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Little CJL, Gettinby G. Heart failure is common in diabetic cats: findings from a retrospective case-controlled study in first-opinion practice. J Small Anim Pract 2007; 49:17-25. [DOI: 10.1111/j.1748-5827.2007.00466.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schermerhorn T, Barr SC. Relationships between glucose, sodium and effective osmolality in diabetic dogs and cats. J Vet Emerg Crit Care (San Antonio) 2006. [DOI: 10.1111/j.1476-4431.2005.00161.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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