A potential diagnostic problem on the ICU: Euglycaemic diabetic Ketoacidosis associated with SGLT2 inhibition

Euglycemic diabetic ketoacidosis caused by empagliflozin complicated by failure to thrive in a geriatric patient

Euglycemic diabetic ketoacidosis (euDKA) is a rare but deadly complication of sodium-glucose cotransport-2 (SGLT-2) inhibitors. Primarily indicated for the treatment of Type 2 Diabetes Mellitus, the incidence of euDKA is expected to rise as SGLT-2 inhibitors become a mainstay therapy for diabetics with heart failure. Diagnosis of euDKA can be difficult given the presence of normoglycemia and is especially challenging among geriatric patients that are complicated by additional comorbidities. We present a case of an elderly male with multiple comorbidities who presented for dehydration and altered mentation from a nursing home facility. Laboratory investigations showed signs of acute renal failure, uremia, electrolyte abnormalities, and severe metabolic acidosis due to high levels of plasma beta-hydroxybutyrate. He was admitted to the medical intensive care unit (ICU) for further management. A presumptive diagnosis of euDKA was strongly suspected due to his laboratory data and medication reconciliation which revealed the recent initiation of empagliflozin. The patient was promptly started on a standardized treatment protocol for DKA with continuous infusion of regular insulin with strict glucose monitoring, along with intravenous fluids, and a small dose of sodium bicarbonate infusion as per current standard guidelines. With the rapid improvement in symptoms and metabolic derangements, the diagnosis was confirmed. Geriatric patients from nursing home facilities are a high-risk cohort who if not properly cared for by nursing staff can develop dehydration, malnutrition and worsening frailty including sarcopenia that exposes them to increased risk of medication side effects, such as euDKA. Clinicians should consider euDKA in their differential diagnosis in elderly patients with overt or relative insulinopenia who are receiving SGLT-2 inhibitors when presenting with acute changes in health and mentation.

Renal medicine in the intensive care unit: a narrative review

Kidney disease, both acute and chronic, is commonly encountered on the intensive care unit. Due to the role the kidneys play in whole body homeostasis, it follows that their dysfunction has wide-ranging implications and can affect prescribing and therapeutic management. This narrative review discusses the pathophysiology of acute kidney injury and chronic kidney disease, and how this relates to critically unwell patients. We cover several aspects of the management of renal dysfunction on the critical care unit, exploring some of the recurrent themes within the literature, including type and timing of kidney replacement therapy, management of acute kidney injury, as well as discussing how novel biomarkers for acute kidney injury may help to identify patients suffering from acute kidney injury as well as risk stratifying these patients. We discuss how early involvement of specialist nephrology services can improve outcomes in patients with kidney disease as well as offer valuable diagnostic and specialist management advice, particularly for patients with established end stage kidney disease and patients who are already known to nephrology services. We also explore some of the ongoing research questions that need to be answered within this arena.

Life-threatening complications for diabetic patients taking SGLT2 inhibitors when undergoing surgery: A poorly recognised problem?

A knowledge of perioperative problems and complications is an important requirement for surgeons. Diabetic patients are a particular group of patients that are specifically at risk of problems. These risks are not only related to the underlying pathophysiological process associated with the disease, but can also occur secondarily to medications used to manage the condition and require careful monitoring, and is of increased importance in the perioperative period. Although a number of medications have historically been used to manage diabetes, a relatively novel group of diabetic medications 'SGLT2 inhibitors' are now being used and have been shown to have many positive attributes, when considering the sequalae of diabetes. However, they have also been associated with significant perioperative problems, which are a consequence of euglycaemic ketoacidosis, a potentially life-threatening condition. Given the significant complications associated with these medications, it is important that practitioners should have an awareness of the problems related to their use. In addition, messages contained in safety releases pertaining to SGLT2 inhibitor use and their risks in patients undergoing surgery, may have been weakened due the timing of their publication in March 2020, during the first UK national lockdown amidst the Coronavirus pandemic.