Management of hepatorenal syndrome and associated outcomes: a systematic reviews.

BACKGROUND: Hepatorenal syndrome (HRS), a multiorgan condition of acute kidney injury, is seen in advanced liver disease. This study aims to evaluate the current treatment for HRS. METHODS: The authors searched PubMed, Scopus and Google Scholar literature. After quality assessment, 31 studies were included in this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology and the population, intervention, comparison and outcome scheme were used. We included human-controlled trials that evaluate the current treatment for HRS. Two authors independently screened articles for inclusion, extracted data and assessed the quality of included studies. RESULTS: This study investigated the studies conducted on the effects of different treatments on follow-up of HRS patients. We gathered 440 articles, so 31 articles remained in our study. Of which 24 articles were conducted on terlipressin versus placebo or other treatments (midodrine/octreotide, norepinephrine, etc) that showed the higher rate of HRS reversal was detected for terlipressin in 17 studies (10 of them were significant), 2 studies achieved an insignificant lower rate of the model for end-stage liver disease score for terlipressin, 15 studies showed a decreased mortality rate in the terlipressin group (4 of them were significant). CONCLUSION: This review showed that terlipressin has a significantly higher reversal rate of HRS than the other treatments. Even the results showed that terlipressin is more efficient than midodrine/octreotide and norepinephrine as a previous medication, in reverse HRS, increasing patient survival.

The superiority of bioimpedance vs. echocardiography and pitting edema in predicting automated office blood pressure in continuous ambulatory peritoneal dialysis patients.

INTRODUCTION: To achieve optimal blood pressure control in continuous ambulatory peritoneal dialysis (CAPD) patients, identifying methods of volume assessment with the strongest correlation with blood pressure is essential. METHODS: In this cross-sectional study, 52 CAPD patients were assigned to automated office blood pressure (AOBP) measurement, assessment of pedal pitting edema, bioimpedance analysis (BIA), and inferior vena cava collapsibility index (IVCCI%) measurement. Data were analyzed using STATA ver.17, and the significance level was p < 0.05. RESULTS: Fifty-two patients were divided based on their AOBP readings. 29 (55.8%) of patients had uncontrolled AOBP. Overhydration (OH) and the grade of pitting edema were significantly higher in the uncontrolled AOBP group. OH was identified as the best variable for predicting blood pressure (p ≤ 0.001) and detecting uncontrolled blood pressure (AUC = 0.832) using multivariate linear regression and ROC analysis, respectively. CONCLUSION: BIA-derived OH was the best variable for predicting systolic and diastolic AOBP, outperforming IVCCI% and pitting edema.

Genetic polymorphisms of glucocorticoid receptor and their association with new-onset diabetes mellitus in kidney transplant recipients.

INTRODUCTION: The variability in developing New-onset Diabetes Mellitus After Transplantation (NODAT), together with previously well-established interindividual variation in glucocorticoid sensitivity, led us to hypothesize that polymorphisms in the NR3C1 gene encoding glucocorticoid receptor may alter glucose balance in kidney transplant recipients. This study aimed to evaluate the association of three functional polymorphisms, BclI, N363S, and ER22/23EK, on the NR3C1 gene with NODAT in kidney allograft recipients. METHODS: From Jun 2020 to July 2022 in Shiraz, 52 patients with NODAT (case group) and 52 non-diabetic kidney transplant recipients (control group) were randomly screened and recruited in this case-control study. The PCR-RFLP technique determined the genotypes of BclI, N363S, and ER22/23EK polymorphisms. RESULTS: The allelic frequencies of the mutant alleles of BclI, N363S, and ER22/23EK polymorphisms in all patients were 0.36, 0.03, and 0.009, respectively. BclI mutant genotypes (CG and GG) were significantly associated with an increased risk of NODAT (P = 0.016), while the two other polymorphisms disclosed no significant association with NODAT development. In the case group, no significant association was detected between the onset time of NODAT and studied polymorphisms, including BclI (P = 0.43), N363S (P = 0.30), and ER22/23EK. P value was not reported for the last polymorphism because all patients with NODAT had the wild-type genotype (GG/GG) and performing statistical analysis was not feasible. Among studied demographic/clinical/paraclinical variables, factors such as higher mean trough level of tacrolimus during the first month after transplantation and higher mean daily dose of prednisolone significantly linked with NODAT development. CONCLUSION: Our data suggested that BclI polymorphism significantly affects NODAT development among Iranian kidney allograft recipients.

The significance of volume overload in the development of pulmonary arterial hypertension in continuous ambulatory peritoneal dialysis patients.

INTRODUCTION: The underlying pathophysiology of pulmonary arterial hypertension (PAH) is multifactorial; however, the significance of chronic volume overload and its subsequent effects on cardiac function must be studied thoroughly. The main objective of this study was to determine the predictive parameters of PAH in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) using transthoracic echocardiography (TTE) and bioimpedance analysis (BIA). METHODS: In this cross-sectional study, 43 eligible CAPD patients were chosen. The patients were examined by TTE and BIA before the morning dialysis session, and baseline patient characteristics, echocardiography, and BIA parameters were recorded. RESULTS: Sixteen (37.2%) patients were diagnosed with PAH. Patients with PAH had significantly greater left atrial diameter (LAD), left ventricular mass index (LVMI), and higher grades of diastolic dysfunction (DDF). Systolic pulmonary artery pressure (sPAP) correlated with LAD (p < 0.001, r = 0.566), interventricular septal diameter (IVSD) (p = 0.004, r = 0.425), LVMI (p = 0.030, r = 0.323), and extracellular water/total body water (ECW/TBW) ratio (p = 0.002, r = 0.458). CONCLUSION: Two volume status-related parameters including ECW/TBW ratio and inferior vena cava (IVC) expiratory diameter, and cardiac-related TTE findings such as LAD and DDF were predictors of sPAP in CAPD patients.

The Epidemiological Characteristics and Outcome of COVID-19 in Patients Undergoing Peritoneal Dialysis: A Multi-center Study in Iran.

The pandemic of COVID-19 emerged in December 2019. Although numerous features of the illness have been investigated, the impact of disease on those patients with underlying diseases, is still a major problem. The aim of this multicenter, cohort study, was to determine the clinical manifestations of COVID-19 in peritoneal dialysis (PD) patients. Five hundred and five patients, receiving PD, were enrolled in this study, out of which 3.7% had coronavirus infection. Fever was the most common symptom (63.2%). The hospitalization rate was 10.5, 21.1% required admission to intensive care units (ICU) and the mortality rate was 21%. The most common cause of infection included close contact with the infected individuals and lower rates of protective equipment use. Although the incidence of COVID-19 among PD patients is low, the severity of the disease and the mortality rate are quite high. Vaccination and adherence to preventive measures are strongly recommended in PD patients.  DOI: 10.52547/ijkd.7147.

Prognosis and Long-Term Overall Survival in Hypertensive Patients Undergoing Chronic Hemodialysis: A Multicenter Parametric Mixture Split-Population Analysis.

BACKGROUND: Hemodialysis (HD) patients face long-term complications which require ongoing dialysis and follow-up. The management of hypertension among HD populations has often been neglected. This study aimed at identifying the determinants of death in hypertensive HD (HTN-HD) patients. METHODS: In a multicenter retrospective cohort study (conducted from 2005 to 2018 in thirty-four HD centers affiliated with Shiraz University of Medical Sciences), the data of 725 HTN-HD patients who had at least 3 months of regular dialysis and follow-up were analyzed. Accelerated failure time mixture split-population (AFTMSP) regression was utilized to identify the factors with significant effects on long- and short-term overall survival (OS) separately. RESULTS: Among the different AFTMSP models, the extended generalized gamma (EGG) model outperformed the others. Sex (male: event time ratio [ETR]=1.30), initial vascular access type (arteriovenous fistula: ETR=1.50), and the type of membrane flux used for HD (high-flux: ETR=1.27) had important impacts on short-term OS. Moreover, age (OR=1.06), dialysis adequacy (Kt/ Vurea≤1.2: OR=2.30), initial vascular access type (central venous catheter: OR=2.08), serum sodium (OR=0.90) concentration, and potassium (OR=0.66) concentration had significant effects on long-term OS. CONCLUSION: The split-population analyses were able to demonstrate that the predictors of long-term OS were different from those of short-term OS. Although the superiority of the parametric EGG model was proved in this study, further research with different databases is suggested. Moreover, these findings can be considered by health policy decision-makers to create a new guideline to enhance the long-term OS of HTN-HD patients.

Clinical and molecular characterization of a patient with mitochondrial Neurogastrointestinal Encephalomyopathy.

BACKGROUND: Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare autosomal recessive disorder caused by mutations in TYMP gene, encoding nuclear thymidine phosphorylase (TP). MNGIE mainly presents with gastrointestinal symptoms and is mostly misdiagnosed in many patients as malabsorption syndrome, inflammatory bowel disease, anorexia nervosa, and intestinal pseudo-obstruction. Up to date, more than 80 pathogenic and likely pathogenic mutations associated with the disease have been reported in patients from a wide range of ethnicities. The objective of this study was to investigate the underlying genetic abnormalities in a 25-year-old woman affected with MNGIE. CASE PRESENTATION: The patient was a 25-year-old female referred to our center with the chief complaint of severe abdominal pain and diarrhea for 2 years that had worsened from 2 months prior to admission. The clinical and para-clinical findings were in favor of mitochondrial neurogastrointestinal encephalomyopathy syndrome. Subsequent genetic studies revealed a novel, private, homozygous nonsense mutation in TYMP gene (c. 1013 C > A, p.S338X). Sanger sequencing confirmed the new mutation in the proband. Multiple sequence alignment showed high conservation of amino acids of this protein across different species. CONCLUSION: The detected new nonsense mutation in the TYMP gene would be very important for genetic counseling and subsequent early diagnosis and initiation of proper therapy. This novel pathogenic variant would help us establish future genotype-phenotype correlations and identify different pathways related to this disorder.

Factors Associated With Short-Term and Long-Term Survival in Patients Undergoing Hemodialysis Using Semi- Parametric Mixture Cure Models.

INTRODUCTION: Understanding the factors affecting the survival of patients undergoing hemodialysis is the mainstay of care in this population. The present study aims at finding these features using novel cure models that discover factors important in both long term and short-term survival of patients undergoing HD. METHODS: Data were retrospectively collected from the database of Shiraz University of Medical Sciences Special Diseases Administration including patients of 34 HD centers during 2011 to 2015. The primary outcome was death. Considering people with no death event as cured, the rest of the patients considered as uncured. To evaluate the factors affecting mortality, we used a mixture cure model (MCM) that model the long-term and short-term survival of patients separately. RESULTS: Of 506 patients, 68.75% of women and 75.0% of men were long-term survivors. The mean (± SD) age of the patients was 57.5 (± 16.5) years and the empirical value of the cure rate was 72.9%. Sex, age, and Kt/Vurea were recognized as important factors in the long-term survival. In other words, lower age, male sex, and Kt/ Vurea ≥ 1.2 significantly increased the odds of being cured. The factors effective in short-term survival were mean corpuscular hemoglobin concentration (MCHC) and serum hemoglobin. The serum hemoglobin between 11 and 12.5 and a high MCHC decreased the risk of death. CONCLUSION: Using cure model survival analysis, it was found that factors affecting the proportion of the patients with long-term survival might be different from those affecting short-term survival.

Ambulatory Blood Pressure Monitoring in Hemodialysis Patients with Intradialytic Hypertension.

INTRODUCTION: It has not yet been clear whether intradialytic hypertension (IDHN) translates into the presence of high BP between dialysis sessions or not. In this study, we aimed to perform interdialytic ambulatory blood pressure monitoring (ABPM) in patients with IDHN to find whether high BP persists at home. METHODS: In this case-control study, ABPM was performed during a 44-hours interdialytic period in patients on maintenance hemodialysis (HD) with pre-dialysis systolic BP (SBP) above 130 mmHg. Bland- Altman graphs were used to investigate the magnitude of the difference between the results of ABPM records and intradialytic BP measurements in patients with and without IDHN. RESULTS: A total of 56 patients were enrolled in our study (29 in the IDHN group and 27 in the control group). The average of the pre-dialysis SBP in 6 consecutive HD treatments was 146.6 ± 11.36 vs. 146.8 ± 12.1 mmHg in IDHN and control group, respectively (P > .05). Mean post-dialysis SBP was 154.45 ± 12.6 mmHg in the IDHN group and 136.76 ± 11.50 in the control group (P < .001). Mean ± SD of 44-hour SBP was 157.31 ± 20.27 mmHg in the IDHN group, which was significantly higher than that in the control group (146.5 ± 16.67 mmHg, P < .05). No significant differences were seen in the average of interdialytic weights gain between the two groups. Compared to the pre-dialysis SBP, using Bland- Altman graphs, the post-dialysis SBP (bias of 3.5 mmHg) had closer readings to the daytime SBP in the IDHN group. CONCLUSION: Patients with IDHN had higher interdialytic BPs. Among BPs taken during HD in patients with IDHN, post-dialysis SBP had the lowest difference with the daytime SBP taken by ABPM.

Duration of Vascular Access Usage and Patient Survival in the First Year of Hemodialysis.

INTRODUCTION: The central venous catheter (CVC) has been shown to increase mortality in hemodialysis (HD) patients compared with the arteriovenous fistula (AVF). However, no study has examined the mortality of HD patients based on the time of conversion from the CVC to AVF. In this study, we investigated the association between patients' survival and length of time of using each access. METHODS: The C5.0 algorithm was used to find rules about the relationship between duration of the different access usage and survival. The cox model was applied to assess the association of the obtained duration categories and mortality. RESULTS: From 2367 adult patients who received maintenance HD from 2012 to 2014, 705 patients were eligible for the study. Using an AVF for more than 8 months and a CVC for less than 4.2 months had the highest one-year survival rate (91.8% and 87.4%). The hazard ratio (HR) for mortality of less than 2.8 months of AVF usage compared to the longest usage was 6.90 (95% CI: 4.60 - 10.30) before adjustment and 5.03 (95% CI: 3.20 - 8.00) after adjustment for all confounders. For the CVC, the ratio was 8.8 (95% CI: 6.00 - 13.00) when comparing more than 9.2 months of usage with the lowest usage duration before an adjustment and 6.00 (95% CI: 3.80 - 9.41) after adjustment. CONCLUSION: Our results presented that regardless of the type of initial vascular access, limiting the length of the time using CVC as well as switching to AVF could significantly improve the survival of HD patients.

Factors influencing survival time of hemodialysis patients; time to event analysis using parametric models: a cohort study.

BACKGROUND: Survival analysis of patients on maintenance hemodialysis (HD) has been the subject of many studies. No study has evaluated the effect of different factors on the survival time of these patients. In this study, by using parametric survival models, we aimed to find the factors affecting survival and discover the effect of them on the survival time. METHODS: As a retrospective cohort study, we evaluated the data of 1408 HD patients. We considered the data of patients who had at least 3 months of HD and started HD from December 2011 to February 2016. The data were extracted from Shiraz University of Medical Sciences (SUMS) Special Diseases database. Primary event was death. We applied Cox-adjusted PH to find the variables with significant effect on risk of death. The effect of various parameters on the survival time was evaluated by a parametric survival model, the one found to have the best fit by Akaike Information Criterion (AIC). RESULTS: Of 428 HD patients eligible for the analysis, 221 (52%) experienced death. With the mean ± SD age of 60 ± 16 years and BMI of 23 ± 4.6 Kg/m, they comprised of 250 men (58%). The median of the survival time (95% CI) was 624 days (550 to 716). The overall 1, 2, 3, and 4-year survival rates for the patients undergoing HD were 74, 42, 25, and 17%; respectively. By using AIC, AFT log-normal model was recognized as the best functional form of the survival time. Cox-adjusted PH results showed that the amount of ultrafiltration volume (UF) (HR = 1.146, P = 0.049), WBC count (HR = 1.039, P = 0.001), RBC count (HR = 0.817, P = 0.044), MCHC (HR = 0.887, P = 0.001), and serum albumin (HR = 0.616, P < 0.001) had significant effects on mortality. AFT log-normal model indicated that WBC (ETR = 0.982, P = 0.018), RBC (ETR = 1.131, P = 0.023), MCHC (ETR = 1.067, P = 0.001), and serum albumin (ETR = 1.232, 0.002) had significant influence on the survival time. CONCLUSION: Considering Cox and three parametric event-time models, the parametric AFT log-normal had the best efficiency in determining factors influencing HD patients survival. Resulting from this model, WBC and RBC count, MCHC and serum albumin are factors significantly affecting survival time of HD patients.

Comparisons between different blood pressure measurement techniques in patients with chronic kidney disease.

BACKGROUND: Automated office blood pressure (AOBP) machines measure blood pressure (BP) multiple times over a brief period. We aimed to compare the results of manual office blood pressure (MOBP) and AOBP methods with ambulatory BP monitoring (ABPM) in patients with chronic kidney disease (CKD). METHODS: This study was performed on 64 patients with CKD (stages 3-4). A nurse manually measured the BP on both arms using a mercury sphygmomanometer, followed by AOBP of the arm with the higher BP and then ABPM. Mean BP readings were compared by paired t test and Bland-Altman graphs. RESULTS: The mean ± standard deviation (SD) age of participants was 59.3 ± 13.6. The mean ± SD awake systolic BP obtained by ABPM was 140.2 ± 19.0 mmHg, which was lower than the MOBP and AOBP methods (156.6 ± 17.8 and 148.8 ± 18.6 mmHg, respectively; P < 0.001). The mean ± SD awake diastolic BP was 78.6 ± 13.2 mmHg by ABPM which was lower than the MOBP and AOBP methods (88.9 ± 13.2 and 84.1 ± 14.0 mmHg, respectively; P < 0.001). Using Bland-Altman graphs, MOBP systolic BP readings showed a bias of 16.4 mmHg, while AOBP measurements indicated a bias of 8.6 mmHg compared with ABPM. CONCLUSION: AOBP methods may be more reliable than MOBP methods for determining BP in patients with CKD. However, the significantly higher mean BPs recorded by AOBP method suggested that AOBPs may not be as accurate as ABPM in patients with CKD.

Potential Adverse Effects of Creatine Supplement on the Kidney in Athletes and Bodybuilders.

INTRODUCTION: Nowadays, creatine is one of the most common oral supplements used by professional athletes for boosting their strength and muscle mass. In this review, we collect available experimental and clinical data about renal safety of both short-term and long-term use of creatine. MATERIALS AND METHODS: Scientific literature was critically searched by keywords "creatine," "renal insufficiency," and "renal dysfunction" and their synonyms in medical databases (Scopus, MEDLINE, EMBase, and ISI Web of Knowledge). Overall, 19 relevant clinical and experimental articles were selected for this review. RESULTS: Short- and long-term creatine supplementations (range, 5 days to 5 years) with different doses (range, 5 g/d to 30 g/d) had no known significant effects on different studied indexes of kidney function such as glomerular filtration rate at least in healthy athletes and bodybuilders with no underlying kidney diseases. In addition, although short-term (range, 5 days to 2 weeks) high-dose oral creatine supplementation (range, 20 g/d to 0.3 g/kg/d) stimulated the production of methylamine and formaldehyde (as potential cytotoxic metabolites of creatine) in the urine of healthy humans, there was currently no definite clinical evidence about their adverse effects on the kidney function. CONCLUSIONS: Although creatine supplementation appears to have no detrimental effects on kidney function of individuals without underlying kidney diseases, it seems more advisable to suggest that creatine supplementation not to be used by sportsmen or women with pre-existing kidney disease or those with a potential risk for kidney dysfunction.

Comparing Therapeutic Efficacy and Safety of Epoetin Beta and Epoetin Alfa in the Treatment of Anemia in End-Stage Renal Disease Hemodialysis Patients.

BACKGROUND: Anemia is one of the most prevalent complications in patients with chronic kidney disease, which is believed to be caused by the insufficient synthesis of erythropoietin by the kidney. This phase III study aimed to compare the efficacy and safety of CinnaPoietin® (epoetin beta, CinnaGen) with Eprex® (epoetin alfa, Janssen Cilag) in the treatment of anemia in ESRD hemodialysis patients. METHODS: In this randomized, active-controlled, double-blind, parallel, and non-inferiority trial, patients were randomized to receive either CinnaPoietin® or Eprex® for a 26-week period. The primary endpoints of this study were to assess the mean hemoglobin (Hb) change during the last 4 weeks of treatment from baseline along with the evaluation of the mean weekly epoetin dosage per kilogram of body weight that was necessary to maintain the Hb level within 10-12 g/dL during the last 4 weeks of treatment. As the secondary objective, safety was assessed along with other efficacy endpoints. RESULTS: A total of 156 patients were included in this clinical trial. There was no statistically significant difference between treatment groups regarding the mean Hb change (p = 0.21). In addition, the mean weekly epoetin dosage per kg of body weight for maintaining the Hb level within 10-12 g/dL showed no statistically significant difference between treatment arms (p = 0.63). Moreover, both products had comparable safety profiles. However, the incidence of Hb levels above 13 g/dL was significantly lower in the CinnaPoietin® group. CONCLUSION: CinnaPoietin® was proved to be non-inferior to Eprex® in the treatment of anemia in ESRD hemodialysis patients. The trial was registered in Clinicaltrials.gov (NCT03408639).

Predictive determinants of scorpion stings in a tropical zone of south Iran: use of mixed seasonal autoregressive moving average model.

BACKGROUND: More than 1.2 million scorpion stings occur annually worldwide, particularly in tropical regions. In the absence of proper medical care, mortality due to venomous scorpion stings is an important public health issue. The aim of the present study is to explore the temporal trend of scorpionism with time series models and determine the effective factors on this event using regression models. METHODS: A retrospective cross sectional study was conducted on 853 scorpion stung patients. They were referred to Haji-Abad Hospital of Hormozgan University of Medical Sciences (HUMS), south Iran, from May 2012 to July 2016. A linear model to describe and predict the monthly trend of scorpion sting cases is fit with autoregressive moving average (ARMA) model. RESULTS: Of 853 victims, 384 (45%) patients were female and 30.2% of them lived in urban areas. The mean (± SD) age of patients was 30.1 (± 19.6) years and the most affected age group was 20-29 years (21.8%). Most victims were unemployed people and farmers (54.7%) followed by housewives (30.2%). The majority of the stings occurred indoors (53.7%), between midnight and 6 a.m. (29.2%), in the summer (44.2%), and the most affected limbs were hands and legs (81.2%). Patient genders and occasions of being stung by scorpions were significantly different between outdoors and indoors (p < 0.001). Scorpion stings due to Odontobuthus doriae were significantly higher than due to other species in urban and rural patients (p = 0.04). Mixed seasonal ARMA at lag 12, ARMA (1, 1) × (0, 1), was selected as the best process for monthly trend of data. Regression results indicated that significant climate factors associated with scorpion stings are temperature (p < 0.001) and relative humidity (p = 0.002). CONCLUSIONS: Scorpion stings have a noticeable effect on tropical rural populations, mainly farmers. Two effective climate factors associated positively and negatively with scorpion sting cases are temperature and relative humidity, respectively. The results of time series and regression models to predict the trends and determinants of scorpion stings are almost the same.

Effect of switching unfractionated heparin to low-molecular-weight heparin on serum potassium in hemodialysis patients.

INTRODUCTION: Unfractionated (UF) heparin is the most common anticoagulant used during hemodialysis. Failure of the kidneys to excrete potassium as well as heparin-induced reduction of aldosterone synthesis put hemodialysis patients at risk of hyperkalemia. It has not yet been clearly known whether hyperkalemia is also induced by low-molecular-weight (LMW) heparins. This study aimed to evaluate the effect of switching UF heparin to LMW heparin enoxaparin, as an anticoagulant during hemodialysis, on serum potassium level in patients on hemodialysis. MATERIAL AND METHODS: In two hemodialysis units, 58 patients were randomly assigned into two groups, to receive two different anticoagulation protocols for 3 weeks; one group continued to receive their routine dose of UF heparin, 5000 units, and the other received enoxaparin, 0.5 mg/kg, at the beginning of each hemodialysis session. RESULTS: While there was no significant difference between baseline blood measurements of the two groups in terms of kidney function tests and electrolytes, following 3 weeks of the study, the mean serum potassium level decreased from 4.9 ± 0.8 mEq/L to 4.5 ± 0.5 mEq/L in the LMW heparin group (P = .001); however, there was no change in the mean serum potassium level in those who continued to receive their usual dose of UF heparin. In a subgroup analysis, diabetic patients in the enoxaparin group did not experience significant reduction in serum potassium levels. CONCLUSIONS: Our study revealed the role of LMW heparins as a potential alternative to UF heparins in the hemodialysis patients with hyperkalemia.

Diabetic ketoalkalosis after steroid pulse therapy in a patient with pancreas transplant rejection.

Diabetic ketoacidosis (DKA) is characterized by excessive production of organic acids leading to a low blood pH. Rarely, because of other complicating factors blood pH may be in the alkalemic range and the term diabetic ketoalkalosis has been coined to describe this condition. So far, less than 30 such cases have been reported in the literature. We report a 34-year-old woman who received methylprednisolone pulse therapy for the treatment of pancreas transplant rejection. Thereafter, she developed vomiting and abdominal pain. Her laboratory data showed high blood sugar, hypokalemia, alkalemic pH, elevated plasma anion gap, and significant ketonemia. She responded well to the treatment of DKA. It was concluded that an alkalemic pH does not rule out the presence of ongoing DKA. In suspected cases, changes in plasma anion gap and bicarbonate and the presence of ketonemia should be noted.