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3.
Medicine (Baltimore) ; 97(50): e13647, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30558060

RESUMO

RATIONALE: Acute kidney injury is common and correctable in patients with a hyperosmolar hyperglycemic state (HHS). Nevertheless, hyperglycemic crisis may also contribute to the development of rhabdomyolysis, which can worsen renal function and lead to high mortality in such patients. PATIENT CONCERNS: Herein, we report a case of hyperosmolar hyperglycemic state-related rhabdomyolysis and acute renal failure with an excellent outcome. DIAGNOSIS: A 26-year-old Asian female with underlying paranoid schizophrenia presented with newly diagnosed type 2 diabetes mellitus complicated with HHS. Her renal function deteriorated rapidly in spite of standard management for hyperglycemic crisis. Rhabdomyolysis was subsequently diagnosed according to the high levels of serum creatine kinase (CK) (37,710 U/L, normal range: 20-180 U/L) and myoglobin (5167.7 ng/mL, normal range: 14.3-65.8 ng/mL). INTERVENTIONS: After treatment failure of intravenous hydration plus loop diuretic agent for rhabdomyolysis related acute renal failure, temporary hemodialysis was performed 3 times to relieve oligouria and pulmonary edema. OUTCOMES: Her renal function recovered well after temporary renal replacement therapy. LESSONS: Rhabdomyolysis is a complication of HHS. Delayed detection can be fatal, and timely renal replacement therapy can result in an excellent prognosis. Therefore, it is crucial for clinicians to detect and treat such patients as early as possible to avoid impairing their renal function.


Assuntos
Lesão Renal Aguda , Diabetes Mellitus Tipo 2/complicações , Coma Hiperglicêmico Hiperosmolar não Cetótico , Diálise Renal/métodos , Rabdomiólise , Esquizofrenia Paranoide/complicações , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Adulto , Creatina Quinase/sangue , Diagnóstico Precoce , Feminino , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Coma Hiperglicêmico Hiperosmolar não Cetótico/etiologia , Coma Hiperglicêmico Hiperosmolar não Cetótico/fisiopatologia , Coma Hiperglicêmico Hiperosmolar não Cetótico/terapia , Testes de Função Renal , Prognóstico , Rabdomiólise/diagnóstico , Rabdomiólise/etiologia , Resultado do Tratamento
5.
Am J Med ; 131(7): 820-828, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29518369

RESUMO

BACKGROUND: After the introduction of the universal definition of myocardial infarction, the incidence and diagnosis of type 2 myocardial infarction have risen dramatically, yet there are no clear guidelines on clinical management. Diabetic patients are at high risk for developing type 2 myocardial infarction when admitted in a decompensated state, and they are also at high risk for future cardiovascular events. METHODS: We performed a retrospective analysis of 1058 patients admitted with diabetic ketoacidosis or hyperosmolar hyperglycemic state between 2011 and 2016. Patients were included if they had cardiac troponin I measured within 24 hours of admission, were older than 18 years of age, and had no evidence of acute coronary syndrome on admission. Baseline characteristics, admission laboratory test results, major adverse cardiovascular events, cardiac stress testing, and coronary angiography data up to 1 year after admission were reviewed. Patients were categorized into 2 groups: those with and those without type 2 myocardial infarction. The study had 2 endpoints: mortality and major adverse cardiac events (MACE) at 1 year and an abnormal result on stress test or coronary angiography at 1 year. RESULTS: Of the 845 patients who met the inclusion criteria, 133 patients (15%) had type 2 myocardial infarction on admission. Patients with type 2 myocardial infarction were at a significantly higher risk for mortality and MACE at 1 year than those without. Patients with type 2 myocardial infarction were also at higher risk for developing an abnormal result on stress test or coronary angiography within 1 year of admission as compared with those without type 2 myocardial infarction (40% vs 24%; odds ratio 2; P = .0699). CONCLUSION: Acutely decompensated diabetic patients with type 2 myocardial infarction are at increased risk for death and MACE. These patients may also be at risk for undiagnosed coronary artery disease.


Assuntos
Diabetes Mellitus Tipo 2/complicações , Cetoacidose Diabética/complicações , Coma Hiperglicêmico Hiperosmolar não Cetótico/complicações , Infarto do Miocárdio/patologia , Doença Aguda , Diabetes Mellitus Tipo 2/mortalidade , Diabetes Mellitus Tipo 2/patologia , Cetoacidose Diabética/diagnóstico , Cetoacidose Diabética/mortalidade , Cetoacidose Diabética/patologia , Feminino , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Coma Hiperglicêmico Hiperosmolar não Cetótico/mortalidade , Coma Hiperglicêmico Hiperosmolar não Cetótico/patologia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Prognóstico , Estudos Retrospectivos , Fatores de Risco
6.
Curr Diabetes Rev ; 14(6): 534-541, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29557753

RESUMO

INTRODUCTION: Although hypovolemia remains the most relevant problem during acute decompensated diabetes in its clinical manifestations (diabetic ketoacidosis, DKA, and hyperglycemic hyperosmolar state, HHS), the electrolyte derangements caused by the global hydroelectrolytic imbalance usually complicate the clinical picture at presentation and may be worsened by the treatment itself. AIM: This review article is focused on the management of dysnatremias during hyperglycemic hyperosmolar state with the aim of providing clinicians a useful tool to early identify the sodium derangement in order to address properly its treatment. DISCUSSION: The plasma sodium concentration is modified by most of the therapeutic measures commonly required in such patients and the physician needs to consider these interactions when treating HHS. Moreover, an improper management of plasma sodium concentration (PNa+) and plasma osmolality during treatment has been associated with two rare potentially life-threatening complications (cerebral edema and osmotic demyelination syndrome). Identifying the correct composition of the fluids that need to be infused to restore volume losses is crucial to prevent complications. CONCLUSION: A quantitative approach based on the comparison between the measured PNa+ (PNa+ M) and the PNa+ expected in the presence of an exclusive water shift (PNa+ G) may provide more thorough information about the true hydroelectrolytic status of the patient and may therefore, guide the physician in the initial management of HHS. On the basis of data derived from our previous studies, we propose a 7-step algorithm to compute an accurate estimate of PNa+ G.


Assuntos
Hidratação/métodos , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Coma Hiperglicêmico Hiperosmolar não Cetótico/terapia , Hipovolemia/complicações , Sódio/sangue , Edema Encefálico/prevenção & controle , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/complicações , Hipernatremia/sangue , Hiponatremia/sangue , Concentração Osmolar
7.
BMJ Case Rep ; 20182018 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-29378735

RESUMO

The authors describe a case of a life-threatening diabetic emergency 25 days after initiation of nivolumab (3 mg/kg) for stage 4 lung adenocarcinoma. She was admitted to the emergency department, with hyperglycaemia-related signs and symptoms, such as polyuria, polydipsia, weight loss, confusion, asthenia, dehydration, hypotension and Kussmaul respiratory pattern. Her body mass index was 21.9 kg/m2 and she did not show acanthosis nigricans. Arterial blood gas determination revealed high anion gap metabolic acidaemia and blood tests showed hyperglycaemia (1060 mg/dL), hyperketonaemia (beta-hydroxybutyrate: 6.6 mmol/dL), elevated total serum osmolality (389 mOsm/kg), low serum and urinary C-peptide and positive antiglutamic acid decarboxylase antibodies. Since nivolumab was initiated a few days before, and due to its known immune-mediated endocrine adverse events, we assumed the diagnosis of new onset immune-mediated type 1 diabetes mellitus. After prompt and adequate treatment of diabetic ketoacidosis/hyperosmolar hyperglycaemic state, she was discharged improved on multiple daily injections of insulin.


Assuntos
Anticorpos Monoclonais/efeitos adversos , Antineoplásicos/efeitos adversos , Diabetes Mellitus Tipo 1/induzido quimicamente , Cetoacidose Diabética/induzido quimicamente , Adenocarcinoma/tratamento farmacológico , Idoso , Diabetes Mellitus Tipo 1/diagnóstico , Cetoacidose Diabética/diagnóstico , Diagnóstico Diferencial , Feminino , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Neoplasias Pulmonares/tratamento farmacológico , Nivolumabe
10.
Pediatr Emerg Care ; 33(12): e172-e174, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29095384

RESUMO

We present the case of a 16-year-old boy who presented with fatigue, polyuria, and polydipsia while on chemotherapy for his relapsed acute lymphoblastic leukemia (ALL). Blood gas examination confirmed the diagnosis of hyperosmolar hyperglycemic state. The etiology for his hyperglycemia was most likely a result of oral glucocorticoid therapy combined with asparaginase therapy-both are a cornerstone of induction chemotherapy for ALL. The patient was aggressively rehydrated with saline, and medications were administered to correct his hyperkalemia. He was then slowly brought to euglycemia with a continuous infusion of insulin. Although hyperosmolar hyperglycemic state is rare during the treatment of ALL, frontline providers should be aware of this diagnosis because of the significant risk of hypovolemic shock and death if correction of hyperglycemia occurs prior to complete fluid resuscitation.


Assuntos
Coma Hiperglicêmico Hiperosmolar não Cetótico/induzido quimicamente , Quimioterapia de Indução/efeitos adversos , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , Adolescente , Hidratação/métodos , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Coma Hiperglicêmico Hiperosmolar não Cetótico/terapia , Quimioterapia de Indução/métodos , Insulina/uso terapêutico , Masculino
12.
Internist (Berl) ; 58(10): 1020-1028, 2017 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-28849301

RESUMO

The diabetic emergencies diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS) and hypoglycemia represent severe and potentially life-threatening complications of diabetes mellitus that require prompt diagnostics and treatment. Absolute or relative insulin insufficiency is characteristic of DKA und HHS along with severe dehydration. They differ by the prevalence of ketone bodies and the severity of acidosis; however, the treatment regimens are similar. In contrast, hypoglycemia is the limiting factor for achieving ambitious glucose targets. This article decribes the clinical presentation, diagnostics and emergency management of these metabolic derangements.


Assuntos
Complicações do Diabetes/diagnóstico , Cetoacidose Diabética/diagnóstico , Emergências , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Hipoglicemia/diagnóstico , Glicemia/metabolismo , Terapia Combinada , Complicações do Diabetes/sangue , Complicações do Diabetes/mortalidade , Complicações do Diabetes/terapia , Cetoacidose Diabética/sangue , Cetoacidose Diabética/mortalidade , Cetoacidose Diabética/terapia , Inibidores da Dipeptidil Peptidase IV/efeitos adversos , Inibidores da Dipeptidil Peptidase IV/uso terapêutico , Diagnóstico Precoce , Intervenção Médica Precoce , Hidratação , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/sangue , Coma Hiperglicêmico Hiperosmolar não Cetótico/mortalidade , Coma Hiperglicêmico Hiperosmolar não Cetótico/terapia , Hipoglicemia/sangue , Hipoglicemia/mortalidade , Hipoglicemia/terapia , Insulina/sangue , Estudos Retrospectivos , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico
13.
Medicine (Baltimore) ; 96(25): e7369, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28640151

RESUMO

RATIONALE: A hyperosmolar hyperglycemic state (HHS) is a rare presentation of a hyperglycemic crisis in children with diabetes mellitus. As this condition can be fatal and has high morbidity, early recognition and proper management are necessary for a better outcome. Here, we report a rare case of HHS as the first presentation of type 1 diabetes mellitus (T1DM) in a 7-year-old girl. PATIENT CONCERNS: The patient was admitted due to polyuria and weight loss in the past few days. The initial blood glucose level was 1167mg/dL. DIAGNOSES: On the basis of clinical manifestations and laboratory results, she was diagnosed with T1DM and HHS. INTERVENTIONS: Treatment was started with intravenous fluid and regular insulin. OUTCOMES: She was discharged without any complications related to HHS and is being followed up in the outpatient clinic with split insulin therapy. LESSONS: As the incidence of T1DM is increasing, emergency physicians and pediatricians should be aware of HHS to make an early diagnosis for appropriate management, as it can be complicated in young children with T1DM.


Assuntos
Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/diagnóstico , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Coma Hiperglicêmico Hiperosmolar não Cetótico/etiologia , Criança , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/terapia , Diagnóstico Diferencial , Feminino , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/sangue , Coma Hiperglicêmico Hiperosmolar não Cetótico/terapia
14.
Med Clin North Am ; 101(3): 587-606, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28372715

RESUMO

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.


Assuntos
Cetoacidose Diabética/diagnóstico , Cetoacidose Diabética/fisiopatologia , Emergências , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Coma Hiperglicêmico Hiperosmolar não Cetótico/fisiopatologia , Bicarbonatos/uso terapêutico , Complicações do Diabetes/diagnóstico , Complicações do Diabetes/fisiopatologia , Cetoacidose Diabética/epidemiologia , Cetoacidose Diabética/terapia , Hidratação , Mortalidade Hospitalar , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/epidemiologia , Coma Hiperglicêmico Hiperosmolar não Cetótico/terapia , Hipoglicemiantes/uso terapêutico , Inflamação/fisiopatologia , Insulina/uso terapêutico , Estresse Oxidativo/fisiologia , Inibidores do Transportador 2 de Sódio-Glicose
15.
Curr Diab Rep ; 17(5): 33, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28364357

RESUMO

PURPOSE OF REVIEW: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the UK and USA. This review delineates the differences in diagnosis and treatment between the two countries. RECENT FINDINGS: Large-scale studies to determine optimal management of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation. There is considerable overlap but important differences between the UK and USA guidelines for the management of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol.


Assuntos
Cetoacidose Diabética/terapia , Coma Hiperglicêmico Hiperosmolar não Cetótico/terapia , Cetoacidose Diabética/diagnóstico , Cetoacidose Diabética/etiologia , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Coma Hiperglicêmico Hiperosmolar não Cetótico/etiologia , Reino Unido , Estados Unidos
16.
Metabolism ; 68: 43-54, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-28183452

RESUMO

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 ß-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.


Assuntos
Complicações do Diabetes/terapia , Diabetes Mellitus/terapia , Serviços Médicos de Emergência/métodos , Hiperglicemia/terapia , Complicações do Diabetes/diagnóstico , Diabetes Mellitus/diagnóstico , Cetoacidose Diabética/terapia , Humanos , Hiperglicemia/diagnóstico , Hiperglicemia/etiologia , Coma Hiperglicêmico Hiperosmolar não Cetótico/diagnóstico , Coma Hiperglicêmico Hiperosmolar não Cetótico/terapia
17.
Korean J Intern Med ; 32(5): 936-938, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-26968192
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