Recent advances in the monitoring and management of diabetic ketoacidosis

Metabolic trajectories of diabetic ketoacidosis onset described by breath analysis

Purpose

This feasibility study aimed to investigate the use of exhaled breath analysis to capture and quantify relative changes of metabolites during resolution of acute diabetic ketoacidosis under insulin and rehydration therapy.

Methods

Breath analysis was conducted on 30 patients of which 5 with DKA. They inflated Nalophan bags, and their metabolic content was subsequently interrogated by secondary electrospray ionization high-resolution mass spectrometry (SESI-HRMS).

Results

SESI-HRMS analysis showed that acetone, pyruvate, and acetoacetate, which are well known to be altered in DKA, were readily detectable in breath of participants with DKA. In addition, a total of 665 mass spectral features were found to significantly correlate with base excess and prompt metabolic trajectories toward an in-control state as they progress toward homeostasis.

Conclusion

This study provides proof-of-principle for using exhaled breath analysis in a real ICU setting for DKA monitoring. This non-invasive new technology provides new insights and a more comprehensive overview of the effect of insulin and rehydration during DKA treatment.

A Novel Acetone Sensor for Body Fluids

Ketones are well-known biomarkers of fat oxidation produced in the liver as a result of lipolysis. These biomarkers include acetoacetic acid and β-hydroxybutyric acid in the blood/urine and acetone in our breath and skin. Monitoring ketone production in the body is essential for people who use caloric intake deficit to reduce body weight or use ketogenic diets for wellness or therapeutic treatments. Current methods to monitor ketones include urine dipsticks, capillary blood monitors, and breath analyzers. However, these existing methods have certain disadvantages that preclude them from being used more widely. In this work, we introduce a novel acetone sensor device that can detect acetone levels in breath and overcome the drawbacks of existing sensing approaches. The critical element of the device is a robust sensor with the capability to measure acetone using a complementary metal oxide semiconductor (CMOS) chip and convenient data analysis from a red, green, and blue deconvolution imaging approach. The acetone sensor device demonstrated sensitivity of detection in the micromolar-concentration range, selectivity for detection of acetone in breath, and a lifetime stability of at least one month. The sensor device utility was probed with real tests on breath samples using an established blood ketone reference method.

Crystalloid Solutions in Hospital: A Review of Existing Literature

Intravenous fluids (IVF) like normal saline (NS) and Ringer's lactate (RL) are often crucial in the management of hospitalized patients. Mishandling these fluids can lead to complications in about 20% of patients receiving them. In this review, we present the current evidence through the identification of observational studies and randomized trials that observed the optimal use of IVF. We found that NS may cause hyperchloremic metabolic acidosis in surgical patients, but there is no clear difference in mortality and long-term outcomes between NS and balanced crystalloids. Critically ill patients, particularly those in sepsis, benefit from balanced crystalloids, as high chloride content fluids like NS increase the risk of complications and mortality. In pancreatitis, NS has been shown to increase the risk of ICU admission when compared to RL; however, there is no significant difference in long-term outcomes and mortality between the fluids. RL is preferred for burns due to its isotonicity and lack of protein, preventing edema formation in an already dehydrated state. Plasma-lyte may resolve diabetic ketoacidosis faster, while prolonged NS use can lead to metabolic acidosis, acute kidney injury, and cerebral edema. In conclusion, NS, RL, and plasma-lyte are the most commonly used isotonic IVF in the hospital population. Incorrect choice of fluids in a different clinical scenario can lead to worse outcomes.

Anticonvulsant Profile of Selected Medium-Chain Fatty Acids (MCFAs) Co-Administered with Metformin in Mice in Acute and Chronic Treatment

In contrast to the other components of the medium-chain triglycerides ketogenic diet (MCT KD), i.e., caprylic acid (CA8), a comprehensive evaluation of caproic (CA6) and lauric acids' (CA12) properties in standard chemical and electrical seizure tests in mice has not yet been performed. We investigated their effects in maximal electroshock seizure threshold (MEST), 6 Hz seizure threshold and intravenous (i.v.) pentylenetetrazole (PTZ) seizure tests. Since ketone body production can be regulated by the activation of 5'AMP-activated protein kinase (AMPK), we hypothesized that metformin (an AMPK activator) enhance ketogenesis and would act synergistically with the fatty acids to inhibit convulsions. We assessed the effects of acute and chronic co-treatment with metformin and CA6/CA8 on seizures. CA6 and CA12 (p.o.) increased seizure threshold in the 6 Hz seizure test. CA6 at the highest tested dose (30 mmol/kg) developed toxicity in several mice, impaired motor performance and induced ketoacidosis. Acute and chronic co-treatment with metformin and CA6/CA8 did not affect seizure thresholds. Moreover, we observed the pro-convulsive effect of the acute co-administration of CA8 (5 mmol/kg) and metformin (100 mg/kg). Since this co-treatment was pro-convulsive, the safety profile and risk/benefit ratio of MCT KD and metformin concomitant therapy in epileptic patients should be further evaluated.

Utility of plasma beta-hydroxybutyrate to define resolution of diabetic ketoacidosis

BACKGROUND

Diabetic ketoacidosis (DKA) is a common, life-threatening complication of type 1 diabetes (T1D) characterized by unregulated ketogenesis caused by relative or absolute insulin deficiency. DKA management requires frequent biochemical monitoring. Plasma ß-hydroxybutyrate (BOHB) has not been included in traditional definitions of DKA resolution.

OBJECTIVE

The aim of this study was to determine a cut-point level of BOHB to define DKA resolution in patients with T1D treated with intravenous (IV) insulin.

SUBJECTS

We identified patients with T1D receiving IV insulin for DKA treatment at a quaternary children's hospital from January 1, 2017 through December 31, 2020 who had plasma measurements of BOHB after DKA onset and whose DKA resolved by traditional laboratory criteria (venous pH (vpH) ≥ 7.3, serum bicarbonate (HCO3 ) ≥ 15 mmol/L, and/or anion gap (AG) ≤ 14 mmol/L).

METHODS

Associations between plasma BOHB and vpH, HCO3 , and AG were evaluated via scatterplots. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were used to evaluate BOHB cut-points to predict DKA resolution.

RESULTS

We analyzed 403 patients with 471 unique encounters. Plasma BOHB showed the most robust relationship with AG. The ROC curve comparing plasma BOHB to the accepted definition of DKA resolution, AG ≤14 mmol/L, had an AUC of 0.92. A BOHB value of <1.5 mmol/L had a sensitivity of 83% and specificity of 87%; this cut-point correctly classified 86% of the observations.

CONCLUSIONS

A plasma BOHB value of <1.5 mmol/L can be used to define resolution of DKA.

Modulation of Reactive Oxygen Species Homeostasis as a Pleiotropic Effect of Commonly Used Drugs

Age-associated diseases represent a growing burden for global health systems in our aging society. Consequently, we urgently need innovative strategies to counteract these pathological disturbances. Overwhelming generation of reactive oxygen species (ROS) is associated with age-related damage, leading to cellular dysfunction and, ultimately, diseases. However, low-dose ROS act as crucial signaling molecules and inducers of a vaccination-like response to boost antioxidant defense mechanisms, known as mitohormesis. Consequently, modulation of ROS homeostasis by nutrition, exercise, or pharmacological interventions is critical in aging. Numerous nutrients and approved drugs exhibit pleiotropic effects on ROS homeostasis. In the current review, we provide an overview of drugs affecting ROS generation and ROS detoxification and evaluate the potential of these effects to counteract the development and progression of age-related diseases. In case of inflammation-related dysfunctions, cardiovascular- and neurodegenerative diseases, it might be essential to strengthen antioxidant defense mechanisms in advance by low ROS level rises to boost the individual ROS defense mechanisms. In contrast, induction of overwhelming ROS production might be helpful to fight pathogens and kill cancer cells. While we outline the potential of ROS manipulation to counteract age-related dysfunction and diseases, we also raise the question about the proper intervention time and dosage.

Controversies Around the Measurement of Blood Ketones to Diagnose and Manage Diabetic Ketoacidosis

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.

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)

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.

Management of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes Mellitus

Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.

Acute pancreatitis secondary to hypertriglyceridemia precipitated by diabetic ketoacidosis in a previously undiagnosed ketosis-prone patient with diabetes mellitus

Diabetic ketoacidosis is a potentially fatal complication of diabetes mellitus that may result in hypertriglyceridemia. Rarely, the resulting hypertriglyceridemia may precipitate acute pancreatitis. We report a case of acute pancreatitis secondary to hypertriglyceridemia precipitated by diabetic ketoacidosis and postulate that this unusual presentation is due to the patient being prone to ketosis.

An Electrochemical Enzyme Biosensor for 3-Hydroxybutyrate Detection Using Screen-Printed Electrodes Modified by Reduced Graphene Oxide and Thionine

A biosensor for 3-hydroxybutyrate (3-HB) involving immobilization of the enzyme 3-hydroxybutyrate dehydrogenase onto a screen-printed carbon electrode modified with reduced graphene oxide (GO) and thionine (THI) is reported here. After addition of 3-hydroxybutyrate or the sample in the presence of NAD⁺ cofactor, the generated NADH could be detected amperometrically at 0.0 V vs. Ag pseudo reference electrode. Under the optimized experimental conditions, a calibration plot for 3-HB was constructed showing a wide linear range between 0.010 and 0.400 mM 3-HB which covers the clinically relevant levels for diluted serum samples. In addition, a limit of detection of 1.0 µM, much lower than that reported using other biosensors, was achieved. The analytical usefulness of the developed biosensor was demonstrated via application to spiked serum samples.

Oxidative toxicity in diabetes and Alzheimer's disease: mechanisms behind ROS/ RNS generation

Reactive oxidative species (ROS) toxicity remains an undisputed cause and link between Alzheimer’s disease (AD) and Type-2 Diabetes Mellitus (T2DM). Patients with both AD and T2DM have damaged, oxidized DNA, RNA, protein and lipid products that can be used as possible disease progression markers. Although the oxidative stress has been anticipated as a main cause in promoting both AD and T2DM, multiple pathways could be involved in ROS production. The focus of this review is to summarize the mechanisms involved in ROS production and their possible association with AD and T2DM pathogenesis and progression. We have also highlighted the role of current treatments that can be linked with reduced oxidative stress and damage in AD and T2DM.

Blood Ketones: Measurement, Interpretation, Limitations, and Utility in the Management of Diabetic Ketoacidosis

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.

Comparison of a 'two-bag system' versus conventional treatment protocol ('one-bag system') in the management of diabetic ketoacidosis

OBJECTIVE

We compared the conventional 'one-bag protocol' of management of diabetic ketoacidosis (DKA) with the 'two-bag protocol' which utilizes two bags of fluids, one containing saline and supplemental electrolytes and the other containing the same solution with the addition of 10% dextrose.

RESEARCH DESIGN AND METHODS

A retrospective chart review and analysis was done on adult patients admitted for DKA to the Riverside University Health System Medical Center from 2008 to 2015. There were 249 cases of DKA managed by the one-bag system and 134 cases managed by the two-bag system.

RESULTS

The baseline patient characteristics were similar in both groups. The anion gap closed in 13.56 hours in the one-bag group versus 10.94 hours in the two-bag group (p value <0.0002). None of the individual factors significantly influenced the anion gap closure time; only the two-bag system favored earlier closure of the anion gap. Plasma glucose levels improved to <250 mg/dL earlier with two-bag protocol (9.14 vs 7.82 hours, p=0.0241). The incidence of hypoglycemic events was significantly less frequent with the two-bag protocol compared with the standard one-bag system (1.49% vs 8.43%, p=0.0064). Neither the time to improve serum HCO₃ level >18 mg/dL nor the hospital length of stay differed between the two groups.

CONCLUSIONS

Our study indicates that the two-bag protocol closes the anion gap earlier than the one-bag protocol in adult patients with DKA. Blood glucose levels improved faster with the two-bag protocol compared with the one-bag protocol with fewer associated episodes of hypoglycemia. Prospective studies are needed to evaluate the clinical significance of these findings.

A Paper-Based "Pop-up" Electrochemical Device for Analysis of Beta-Hydroxybutyrate

This paper describes the design and fabrication of a "pop-up" electrochemical paper-based analytical device (pop-up-EPAD) to measure beta-hydroxybutyrate (BHB)-a biomarker for diabetic ketoacidosis-using a commercial combination BHB/glucometer. Pop-up-EPADs are inspired by pop-up greeting cards and children's books. They are made from a single sheet of paper folded into a three-dimensional (3D) device that changes shape, and fluidic and electrical connectivity, by simply folding and unfolding the structure. The reconfigurable 3D structure makes it possible to change the fluidic path and to control timing; it also provides mechanical support for the folded and unfolded structures that enables good registration and repeatability on folding. A pop-up-EPAD designed to detect BHB shows performance comparable to commercially available plastic test strips over the clinically relevant range of BHB in blood when used with a commercial glucometer that integrates the ability to measure glucose and BHB (combination BHB/glucometer). With simple modifications of the electrode and the design of the fluidic path, the pop-up-EPAD also detects BHB in buffer using a simple glucometer-a device that is more available than the combination BHB/glucometer. Strategies that use a "3D pop-up"-that is, large-scale changes in 3D structure and fluidic paths-by folding/unfolding add functionality to EPADs (e.g., controlled timing, fluidic handling and path programming, control over complex sequences of steps, and alterations in electrical connectivity) and should enable the development of new classes of paper-based diagnostic devices.

Comparing Finger-stick β-Hydroxybutyrate with Dipstick Urine Tests in the Detection of Ketone Bodies

OBJECTIVES

Blood ketone (beta-hydroxybutyrate) measurements are suggested instead of urine ketone (acetoacetate) measurements in the diagnosis of diabetic ketoacidosis. Urine ketone examination is difficult and time consuming, and may result in an incorrect interpretation. Studies performed in emergency departments on blood ketones are limited. Our objective is to compare urine ketones and capillary blood ketones in patients whose serum glucose levels were ≥150 mg/dl.

METHODS

In our cross-sectional prospective study, finger-stick blood beta-hydroxybutyrate, arterial blood gas and urine ketone measurements of patients whose serum glucose levels were 150 mg/dL and higher were performed in the emergency department.

RESULTS

A total of 265 patients were included in the study. The mean age of the patients was 62.4±14.9 years, and 65.7% of them were female. The mean of the capillary blood ketone levels of the patients was determined to be 0.524±0.9 mmol/L (min: 0 mmol/L, max: 6.7 mmol/L). In 29 (13.1%) of the 221 patients whose urine ketone levels were negative, the finger-stick blood ketone levels were positive. Three of these patients were severely ketonemic, six were moderately ketonemic, and 20 were mildly ketonemic.

CONCLUSIONS

In patients admitted to the emergency department with a blood glucose level of 150 mg/dL or higher, performing a capillary blood ketone measurement instead of a urine ketone measurement was a better predictor of ketonemia.

Lactation Ketoacidosis: An Unusual Entity and a Review of the Literature

A 31-year-old woman presented to the hospital with symptoms of nausea, malaise, and emesis. She was breastfeeding her 10-month-old infant. She was found to have severe ketoacidosis. The patient was not in diabetic ketoacidosis or alcoholic ketoacidosis; nor had she ingested any toxins. After she was admitted to the hospital, received intravenous fluids, and stopped breastfeeding, her symptoms resolved. She was found to have lactation ketoacidosis, an uncommon condition in humans. A review of all causes of ketoacidosis is presented with special emphasis on lactation ketocacidosis.

Clinical characteristics of patients with diabetic ketoacidosis at the Intensive Care Unit of a University Hospital

Objectives:

The aims of this study were assessing the frequency of clinical characteristics of patients with severe Diabetic ketoacidosis (DKA) who were admitted to the intensive care unit (ICU) and investigating the relationship between paraclinical (glucose, anion gap, and serum bicarbonate) and clinical parameters in patients with severe DKA.

Method:

A retrospective chart review of all adult patients with DKA who were admitted to the ICU at King Abdulaziz University Hospital, Jeddah, Saudi Arabia between January 2012 and December 2013. The data collected include the demographic data, clinical presentation, precipitating factors, duration of hospital stay and mortality rate. The data were analyzed using STAT software.

Results:

A total of 60 patients were included. Of these, 50 were men (83.3%). The median age was 23 years (ranging 18-29 years). Newly diagnosed diabetics accounted for 15 (25%) of the cases; the remainder were previously known patients of type1 diabetes on treatment. The main precipitating factors of DKA were insulin treatment cessation (87.5%) and infection/sepsis (39.6%). Serum blood glucose, serum bicarbonate level, and the calculated anion gap did not significantly correlate with clinical parameters of severe DKA.

Conclusion:

Most patients with severe DKA who were admitted to the ICU of our institution presented with gastrointestinal symptoms. Non-compliance to insulin therapy was the main precipitating factor of DKA.

Respiratory failure in diabetic ketoacidosis

Respiratory failure complicating the course of diabetic ketoacidosis (DKA) is a source of increased morbidity and mortality. Detection of respiratory failure in DKA requires focused clinical monitoring, careful interpretation of arterial blood gases, and investigation for conditions that can affect adversely the respiration. Conditions that compromise respiratory function caused by DKA can be detected at presentation but are usually more prevalent during treatment. These conditions include deficits of potassium, magnesium and phosphate and hydrostatic or non-hydrostatic pulmonary edema. Conditions not caused by DKA that can worsen respiratory function under the added stress of DKA include infections of the respiratory system, pre-existing respiratory or neuromuscular disease and miscellaneous other conditions. Prompt recognition and management of the conditions that can lead to respiratory failure in DKA may prevent respiratory failure and improve mortality from DKA.

Role of the adenosine system and glucose restriction in the acute anticonvulsant effect of caprylic acid in the 6 Hz psychomotor seizure test in mice

Although several studies have reported the acute anticonvulsant activity of caprylic acid in animal seizure models, little is known about the mechanism underlying this effect. Recently, the role of adenosine in the efficacy of the ketogenic diet has been postulated. Therefore, the present study aimed to evaluate the possible involvement of the adenosine system (in non-fasted mice) as well as the role of glucose restriction (in fasted and non-fasted mice) in the acute anticonvulsant activity of caprylic acid in the 6 Hz psychomotor seizure threshold test. We showed that the anticonvulsant effect of caprylic acid (30 mmol/kg, p.o.) was reversed by a selective adenosine A1 receptor antagonist (DPCPX, 1mg/kg, i.p.) and a selective adenosine A2A receptor antagonist (KW-6002, 1 mg/kg, p.o.) but not by glibenclamide (1 pg/mouse, i.c.v.) - the ATP-sensitive potassium (KATP) channel blocker. Co-administration of an ineffective dose of caprylic acid (20 mmol/kg) with an ineffective dose of adenosine transporter inhibitor (dipyridamole, 50 mg/kg, i.p.) significantly raised the threshold for the 6 Hz-induced seizures. A high dose of glucose (2 g/kg) significantly only diminished the anticonvulsant effect of caprylic acid (30 mmol/kg) in non-fasted mice, and this was accompanied by an increase in blood glucose level and no changes in ketone body level as compared to the caprylic acid-treated group. In both fasted and non-fasted mice treated with glucose and caprylic acid, a significant decrease in trunk blood pH occurred as compared to the control group. No alternations in motor coordination or muscular strength were noted with any drug treatment, apart from the caprylic acid and glibenclamide combination, where a significant decrease in the muscle strength was observed. The present study provides a new insight into the role of the adenosine system and low glucose usage in the mechanisms underlying the anticonvulsant effects of caprylic acid in the 6 Hz seizure test.

Utility of ketone measurement in the prevention, diagnosis and management of diabetic ketoacidosis

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.

A low-glycemic index meal and bedtime snack prevents postprandial hyperglycemia and associated rises in inflammatory markers, providing protection from early but not late nocturnal hypoglycemia following evening exercise in type 1 diabetes

OBJECTIVE

To examine the influence of the glycemic index (GI) of foods consumed after evening exercise on postprandial glycemia, metabolic and inflammatory markers, and nocturnal glycemic control in type 1 diabetes.

RESEARCH DESIGN AND METHODS

On two evenings (∼1700 h), 10 male patients (27 ± 5 years of age, HbA1c 6.7 ± 0.7% [49.9 ± 8.1 mmol/mol]) were administered a 25% rapid-acting insulin dose with a carbohydrate bolus 60 min before 45 min of treadmill running. At 60 min postexercise, patients were administered a 50% rapid-acting insulin dose with one of two isoenergetic meals (1.0 g carbohdyrate/kg body mass [BM]) matched for macronutrient content but of either low GI (LGI) or high GI (HGI). At 180 min postmeal, the LGI group ingested an LGI snack and the HGI group an HGI snack (0.4 g carbohdyrate/kg BM) before returning home (∼2300 h). Interval samples were analyzed for blood glucose and lactate; plasma glucagon, epinephrine, interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α); and serum insulin, cortisol, nonesterified fatty acid, and β-hydroxybutyrate concentrations. Interstitial glucose was recorded for 20 h postlaboratory attendance through continuous glucose monitoring.

RESULTS

Following the postexercise meal, an HGI snack induced hyperglycemia in all patients (mean ± SD glucose 13.5 ± 3.3 mmol/L) and marked increases in TNF-α and IL-6, whereas relative euglycemia was maintained with an LGI snack (7.7 ± 2.5 mmol/L, P < 0.001) without inflammatory cytokine elevation. Both meal types protected all patients from early hypoglycemia. Overnight glycemia was comparable, with a similar incidence of nocturnal hypoglycemia (n = 5 for both HGI and LGI).

CONCLUSIONS

Consuming LGI food with a reduced rapid-acting insulin dose following evening exercise prevents postprandial hyperglycemia and inflammation and provides hypoglycemia protection for ∼8 h postexercise; however, the risk of late nocturnal hypoglycemia remains.

Accuracy of capillary blood 3-β-hydroxybutyrate determination for the detection and treatment of canine diabetic ketoacidosis

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.

Diabetic ketoacidosis in pregnancy

Pregnancies complicated by diabetic ketoacidosis are associated with increased rates of perinatal morbidity and mortality. A high index of suspicion is required, because diabetic ketoacidosis onset in pregnancy can be insidious, usually at lower glucose levels, and often progresses more rapidly as compared with nonpregnancy. Morbidity and mortality can be reduced with early detection of precipitating factors (ie, infection, intractable vomiting, inadequate insulin management or inappropriate insulin cessation, β-sympathomimetic use, steroid administration for fetal lung maturation), prompt hospitalization, and targeted therapy with intensive monitoring. A multidisciplinary approach including a maternal-fetal medicine physician, medical endocrinology specialists familiar with the physiologic changes in pregnancy, an obstetric anesthesiologist, and skilled nursing is paramount. Management principles include aggressive volume replacement, initiation of intravenous insulin therapy, correction of acidosis, correction of electrolyte abnormalities and management of precipitating factors, as well as monitoring of maternal-fetal response to treatment. When diabetic ketoacidosis occurs after 24 weeks of gestation, fetal status should be continuously monitored given associated fetal hypoxemia and acidosis. The decision for delivery can be challenging and must be based on gestational age as well as maternal-fetal responses to therapy. The natural inclination is to proceed with emergent delivery for nonreassuring fetal status that is frequently present during the acute episode, but it is imperative to correct the maternal metabolic abnormalities first, because both maternal and fetal conditions will likewise improve. Prevention strategies should include education of diabetic pregnant women about the risks of diabetic ketoacidosis, precipitating factors, and the importance of reporting signs and symptoms in a timely fashion.

Neurologic complications of electrolyte disturbances and acid-base balance

Electrolyte and acid-base disturbances are common occurrences in daily clinical practice. Although these abnormalities can be readily ascertained from routine laboratory findings, only specific clinical correlates may attest as to their significance. Among a wide phenotypic spectrum, acute electrolyte and acid-base disturbances may affect the peripheral nervous system as arreflexic weakness (hypermagnesemia, hyperkalemia, and hypophosphatemia), the central nervous system as epileptic encephalopathies (hypomagnesemia, dysnatremias, and hypocalcemia), or both as a mixture of encephalopathy and weakness or paresthesias (hypocalcemia, alkalosis). Disabling complications may develop not only when these derangements are overlooked and left untreated (e.g., visual loss from intracranial hypertension in respiratory or metabolic acidosis; quadriplegia with respiratory insufficiency in hypermagnesemia) but also when they are inappropriately managed (e.g., central pontine myelinolisis when rapidly correcting hyponatremia; cardiac arrhythmias when aggressively correcting hypo- or hyperkalemia). Therefore prompt identification of the specific neurometabolic syndromes is critical to correct the causative electrolyte or acid-base disturbances and prevent permanent central or peripheral nervous system injury. This chapter reviews the pathophysiology, clinical investigations, clinical phenotypes, and current management strategies in disorders resulting from alterations in the plasma concentration of sodium, potassium, calcium, magnesium, and phosphorus as well as from acidemia and alkalemia.

Management of adult diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Elements of management include making the appropriate diagnosis using current laboratory tools and clinical criteria and coordinating fluid resuscitation, insulin therapy, and electrolyte replacement through feedback obtained from timely patient monitoring and knowledge of resolution criteria. In addition, awareness of special populations such as patients with renal disease presenting with DKA is important. During the DKA therapy, complications may arise and appropriate strategies to prevent these complications are required. DKA prevention strategies including patient and provider education are important. This review aims to provide a brief overview of DKA from its pathophysiology to clinical presentation with in depth focus on up-to-date therapeutic management.

Incidence and mortality of diabetic ketoacidosis in benghazi-libya in 2007

OBJECTIVE

The aim of this study was to estimate the incidence of diabetic ketoacidosis and the mortality rate at Benghazi city.

METHODS

A cross-sectional study of the records of all patients admitted with diabetic ketoacidosis to all Benghazi hospitals (governmental and private) between 1st of January and 31st of December 2007.

RESULTS

The annual incidence of diabetic ketoacidosis was 41.7 episodes/100,000 populations with a mean age of 33±20.1 years (2-93). Around 52% of all the episodes occurred in males and 2.6% of adult Diabetic ketoacidosis occurred in pregnant females. Type-2 diabetics were responsible for 27.7% of all episodes. The commonest precipitating factor in the whole study group was dose disruption (35%), followed by infection (20%). The most common presenting symptoms were gastrointestinal, whilst 3.5% of the patients were comatose at presentation. The overall mortality was 11.7% and there was no significant difference in mortality between males and females (11% vs. 12.6%; p=0.6); however, type-2 diabetics showed a significantly higher mortality rate (29.3% vs. 4.9%; p=0.000).

CONCLUSION

Diabetic ketoacidosis is a common condition in Libya with a high mortality rate and type-2 diabetics constitute a considerable number of the cases.

Development of 3-hydroxybutyrate dehydrogenase enzyme biosensor based on carbon nanotube-modified screen-printed electrode

Precise detection of 3-hydroxybutyrate (HB) in biological samples is of great importance for management of diabetic patients. In this study, an HB biosensor based on single-walled carbon nanotubes (SWCNTs)-modified screen-printed electrode (SPE) was developed to determine the concentration of HB in serum. The specific detecting enzyme, HB dehydrogenase, was physically immobilised on SWCNTs deposited on the surface of SPEs. The electrochemical measurement of HB that involved cyclic voltammetry was based on the sAgnal produced by j3-nicotinamide adenine dinucleotide (NADH), one of the products of the enzymatic reaction. The application of SWCNT reduced the oxidation potential of NADH to about -0.05 V. Electrochemical measurements showed that the response of this biosensor had relevant good linearity in the range of 0.1-2 mM with a low detection limit of 0.009 mM. Investigation of biosensor response in the presence of interfering molecules verified its specificity. Furthermore, the study of long-term stability demonstrated the acceptable efficiency of this biosensor for about 100 days.

An electrochemical biosensor for 3-hydroxybutyrate detection based on screen-printed electrode modified by coenzyme functionalized carbon nanotubes

3-Hydroxybutyrate, one of the main blood ketone bodies, has been considered as a critical indicator for diagnosis of diabetic ketoacidosis. Biosensors designed for detection of 3-hydroxybutyrate with advantages of precision, easiness and speedy performance have attracted increasing attention. This study attempted to develop a 3-hydroxybutyrate dehydrogenase-based biosensor in which single-walled carbon nanotubes (SWCNT) was used in order to immobilize the cofactor, NAD(+), on the surface of screen-printed electrode. The formation of NAD(+)-SWCNT conjugates was assessed by electrochemistry and electron microscopy. Cyclic voltammetry was used to analyze the performance of this biosensor electrochemically. The considerable shelf life and reliability of the proposed biosensor to analyze real sample was confirmed by this method. The reduction in the over potential of electrochemical oxidation of NADH to -0.15 V can be mentioned as a prominent feature of this biosensor. This biosensor can detect 3-hydroxybutyrate in the linear range of 0.01-0.1 mM with the low detection limit of 0.009 mM. Simultaneous application of screen-printed electrode and SWCNT has made the biosensor distinguished which can open new prospects for detection of other clinically significant metabolites.

Fluid management in diabetic-acidosis--Ringer's lactate versus normal saline: a randomized controlled trial

OBJECTIVE

To determine if Ringer's lactate is superior to 0.9% sodium chloride solution for resolution of acidosis in the management of diabetic ketoacidosis (DKA).

DESIGN

Parallel double blind randomized controlled trial.

METHODS

Patients presenting with DKA at Kalafong and Steve Biko Academic hospitals were recruited for inclusion in this study if they were >18 years of age, had a venous pH >6.9 and ≤7.2, a blood glucose of >13 mmol/l and had urine ketones of ≥2+. All patients had to be alert enough to give informed consent and should have received <1 l of resuscitation fluid prior to enrolment.

RESULTS

Fifty-seven patients were randomly allocated, 29 were allocated to receive 0.9% sodium chloride solution and 28 to receive Ringer's lactate (of which 27 were included in the analysis in each group). An adjusted Cox proportional hazards analysis was done to compare the time to normalization of pH between the 0.9% sodium chloride solution and Ringer's lactate groups. The hazard ratio (Ringer's compared with 0.9% sodium chloride solution) for time to venous pH normalization (pH = 7.32) was 1.863 (95% CI 0.937-3.705, P = 0.076). The median time to reach a pH of 7.32 for the 0.9% sodium chloride solution group was 683 min (95% CI 378-988) (IQR: 435-1095 min) and for Ringer's lactate solution 540 min (95% CI 184-896, P = 0.251). The unadjusted time to lower blood glucose to 14 mmol/l was significantly longer in the Ringer's lactate solution group (410 min, IQR: 240-540) than the 0.9% sodium chloride solution group (300 min, IQR: 235-420, P = 0.044). No difference could be demonstrated between the Ringer's lactate and 0.9% sodium chloride solution groups in the time to resolution of DKA (based on the ADA criteria) (unadjusted: P = 0.934, adjusted: P = 0.758)

CONCLUSION

This study failed to indicate benefit from using Ringer's lactate solution compared to 0.9% sodium chloride solution regarding time to normalization of pH in patients with DKA. The time to reach a blood glucose level of 14 mmol/l took significantly longer with the Ringer's lactate solution.

Measurement of β-hydroxybutyrate in cats with nonketotic diabetes mellitus, diabetic ketosis, and diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). The standard method of detection of ketone bodies is the dipstick method, which detects semiquantitatively acetoacetate, but not β-hydroxybutyrate (β-HB). The objectives of the current study were to assess the diagnostic utility of β-HB to diagnose diabetic ketosis (DK) and DKA in cats and to establish a cut-off value for the diagnosis of DKA. Sixty-two cats were included in the study. Eleven cats were healthy (group 1); in the remainder of cats (51), a diagnosis of DM was based on hyperglycemia, glucosuria, and increased fructosamine concentrations. Nineteen of 51 cats suffered from nonketotic diabetes mellitus (group 2). In 11 cats, plasma ketone bodies were detected with the dipstick method (diabetic ketosis, group 3). In 21 cats, plasma ketone bodies and metabolic acidosis were present (DKA, group 4). Plasma β-HB was measured in all cats by an enzymatic method (spectrophotometry). A cut-off value for the diagnosis of DKA was calculated based on the receiver operating characteristic curve. In healthy cats, the β-HB concentration ranged from 0 to 0.1 mmol/l; in cats of group 2, from 0 to 0.9 mmol/l (median: 0.1 mmol/l); in cats of group 3, from 0.6 to 6.8 mmol/l (median: 1.7 mmol/l); and in cats of group 4, from 3.8 to 12.2 mmol/l (median: 7.9 mmol/l). A cut-off value of 2.4 mmol/l revealed 100% sensitivity and 87% specificity to diagnose DKA. Beta-hydroxybutyrate is a useful parameter for the diagnosis of diabetic ketosis and DKA in cats.

[Capillary beta-hydroxybutyrate determination for monitoring diabetic ketoacidosis]

BACKGROUND AND OBJECTIVE

Diabetic ketoacidosis (DKA) is the most severe acute metabolic complication of type 1 diabetes mellitus. Insulin treatment is commonly guided by plasma glucose levels and changes in venous blood gases, while β-hydroxibutyrate (BHB) levels are rarely measured. The study objective was to evaluate the value of capillary BHB monitoring in the course and resolution of DKA.

PATIENTS AND METHODS

Thirty patients with type 1 diabetes admitted for DKA were enrolled. A standard protocol including monitoring of blood glucose, venous blood gases, semiquantitative ketonuria, and capillary BHB was used. Patients were divided into three groups by time to DKA resolution (group 1:<24 h, group 2: 24-48 h, group 3: >48 h), and BHB results were compared to all other biochemical measurements.

RESULTS

Mean laboratory results upon admission were: blood glucose 415 (standard deviation [SD] 106) mg/dL; bicarbonate 9.6 (SD 1.5) mmol/L; pH 7.13 (SD 0.04); BHB 4.33 (SD 0.48) mmol/L, and ketonuria 3+ in 22 patients and 4+ in 6. BHB correlated well with bicarbonate (r=-0.24139; P=0.0161) and pH (r=-0.56419; P<0.0001). BHB normalized earlier than ketonuria in all cases (group 1: 15.5 vs 18.8 hours P<0.05; group 2: 18.2 vs 23.5 hours P<0.01; group 3: 37.3 vs 41.7 hours P<0.01). Ten percent of patients still had ketonuria when blood ketone levels were already normal (<0.5 mmol/L).

CONCLUSION

BHB measurement is an easy, practical, and reliable monitoring method in DKA and may be used as a parameter to adjust insulin treatment.

Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis

The Joint British Diabetes Societies guidelines for the management of diabetic ketoacidosis (these do not cover Hyperosmolar Hyperglycaemic Syndrome) are available in full at: (i) http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/The-Management-of-Diabetic-Ketoacidosis-in-Adults; (ii)  http://www.diabetes.nhs.uk/publications_and_resources/reports_and_guidance; (iii) http://www.diabetologists-abcd.org.uk/JBDS_DKA_Management.pdf. This article summarizes the main changes from previous guidelines and discusses the rationale for the new recommendations. The key points are: Monitoring of the response to treatment (i) The method of choice for monitoring the response to treatment is bedside measurement of capillary blood ketones using a ketone meter. (ii) If blood ketone measurement is not available, venous pH and bicarbonate should be used in conjunction with bedside blood glucose monitoring to assess treatment response. (iii) Venous blood should be used rather than arterial (unless respiratory problems dictate otherwise) in blood gas analysers. (iv) Intermittent laboratory confirmation of pH, bicarbonate and electrolytes only. Insulin administration (i) Insulin should be infused intravenously at a weight-based fixed rate until the ketosis has resolved. (ii) When the blood glucose falls below 14 mmol/l, 10% glucose should be added to allow the fixed-rate insulin to be continued. (iii) If already taking, long-acting insulin analogues such as insulin glargine (Lantus(®), Sanofi Aventis, Guildford, Surry, UK) or insulin detemir (Levemir(®), Novo Nordisk, Crawley, West Sussex, UK.) should be continued in usual doses. Delivery of care (i) The diabetes specialist team should be involved as soon as possible. (ii) Patients should be nursed in areas where staff are experienced in the management of ketoacidosis.

Impact of pre-exercise rapid-acting insulin reductions on ketogenesis following running in Type 1 diabetes

AIM

This study examined the effects of reductions to pre-exercise rapid-acting insulin dose on changes in blood beta-hydroxybutyrate, glucose, acid-base balance and counter-regulatory hormone responses to prolonged running in individuals with Type 1 diabetes.

METHODS

Following ethical approval, seven participants with Type 1 diabetes (34±2 years, BMI 27±1 kg/m(2) ) completed this study. After preliminary testing, participants attended the laboratory four times, each time consuming a 1.12 MJ meal (60 g carbohydrate, 2 g fat, 2 g protein), with randomized amounts of their rapid-acting insulin: Full dose (mean 7.3±0.2 units), 75% dose (mean 5.4±0.1 units), 50% dose (mean 3.7±0.1 units) or 25% dose (mean 1.8±0.1 units). After 2-h rest, participants completed 45 min running at 70±1% peak rate of oxygen consumption (VO(2peak) ). Blood metabolites and hormones were recorded over the 2-h rest and 3-h recovery. Data were analysed using repeated-measures ANOVA.

RESULTS

  Serum insulin peaked at 60 min in all conditions and was lowest after 25% insulin dose compared with full dose (P=0.03). After the 25% insulin dose immediately pre-exercise glucose concentration was higher than after the full or 50% dose (P<0.05). Resting beta-hydroxybutyrate gradually decreased during 2-h rest (P<0.05) with a similar post-exercise peak of beta-hydroxybutyrate at 3 h (P>0.05). Post-exercise blood pH increased for 5 min to a similar extent with all insulin doses , but the rise with the 25% dose was less compared with the full dose (P=0.01). Blood lactate and plasma catecholamines increased after running similarly with all insulin reduction conditions (P<0.05). Blood glucose area under the curve (BG(auc) ) after the 25% insulin dose was greater than after the 75% dose (P=0.02).

CONCLUSION

Ketogenesis following running was not influenced by reductions in pre-exercise rapid-acting insulin dose. This important preparatory strategy aids preservation of blood glucose but poses no greater risk to exercise-induced ketone body formation.

Diabetes-related molecular signatures in infrared spectra of human saliva

BACKGROUND

There is an ongoing need for improvements in non-invasive, point-of-care tools for the diagnosis and prognosis of diabetes mellitus. Ideally, such technologies would allow for community screening.

METHODS

In this study, we employed infrared spectroscopy as a novel diagnostic tool in the prediction of diabetic status by analyzing the molecular and sub-molecular spectral signatures of saliva collected from subjects with diabetes (n = 39) and healthy controls (n = 22).

RESULTS

Spectral analysis revealed differences in several major metabolic components - lipid, proteins, glucose, thiocyanate and carboxylate - that clearly demarcate healthy and diseased saliva. The overall accuracy for the diagnosis of diabetes based on infrared spectroscopy was 100% on the training set and 88.2% on the validation set. Therefore, we have established that infrared spectroscopy can be used to generate complex biochemical profiles in saliva and identify several potential diabetes-associated spectral features.

CONCLUSIONS

Infrared spectroscopy may represent an appropriate tool with which to identify novel diseases mechanisms, risk factors for diabetic complications and markers of therapeutic efficacy. Further study into the potential utility of infrared spectroscopy as diagnostic and prognostic tool for diabetes is warranted.

The performance of a glucose-ketone meter in the diagnosis of diabetic ketoacidosis in patients with type 2 diabetes in the emergency room

BACKGROUND

Diabetic ketoacidosis (DKA) is a serious metabolic complication. One of its precipitating causes is insulin omission. DKA requires early diagnosis and strict glucose control, which increases the use of glucose meters in the Emergency Room (ER). We aimed to determine the performance of a glucose-ketone meter in the diagnosis of DKA.

METHODS

From 450 type 2 diabetes mellitus insulin-treated patients attending the ER with a capillary glucose level >13.9 mmol/L, 50 patients (26 men and 24 women, mean age 60.2 +/- 8.2 years) had DKA. Capillary glucose and beta-hydroxybutyrate (beta-OHB) were measured with the Precision-Xtra device (Abbott Laboratories, Abingdon, UK). Serum glucose and biochemical parameters were measured on an automatic analyzer; serum beta-OHB was determined using an enzymatic end-point spectrophotometric method. Urine ketones were determined using a semiquantitative assay (Ketodiastix, Bayer Diagnostics, Stoke Poges, Slough, UK).

RESULTS

Serum and capillary beta-OHB values were highly correlated (r = 0.99, P < 0.001), and the mean difference between them was 0.49 mmol/L (95% confidence interval [CI], 0.35-0.95 mmol/L; P = 0.81). Similarly, serum and capillary glucose values were significantly correlated (r = 0.86, P < 0.001), and the mean difference between them was 0.43 mmol/L (95% CI, 0.82-0.93 mmol/L; P = 0.71). Patients with DKA were inadequately treated with insulin and missed clinic appointments: 80% of patients with DKA compared to 20% of patients without DKA. In all cases, DKA was attributed to insulin omission. Capillary ketonemia (beta-OHB >3.0 mmol/L) had the highest performance (sensitivity 99.87%, specificity 92.89%, positive predictive value 92.89%) for the diagnosis of DKA compared with serum ketonemia (sensitivity 90.45%, specificity 88.65%, positive predictive value 87.76%) or ketonuria (sensitivity 89.89%, specificity 52.73%, positive predictive value 41.87%).

CONCLUSIONS

Implementation of measures such as home glucose and ketone monitoring can possibly decrease the number of hospital admissions due to DKA.

Practical steps to improving the management of type 1 diabetes: recommendations from the Global Partnership for Effective Diabetes Management

The Diabetes Control and Complications Trial (DCCT) led to considerable improvements in the management of type 1 diabetes, with the wider adoption of intensive insulin therapy to reduce the risk of complications. However, a large gap between evidence and practice remains, as recently shown by the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, in which 30-year rates of microvascular complications in the 'real world' EDC patients were twice that of DCCT patients who received intensive insulin therapy. This gap may be attributed to the many challenges that patients and practitioners face in the day-to-day management of the disease. These barriers include reaching glycaemic goals, overcoming the reality and fear of hypoglycaemia, and appropriate insulin therapy and dose adjustment. As practitioners, the question remains: how do we help patients with type 1 diabetes manage glycaemia while overcoming barriers? In this article, the Global Partnership for Effective Diabetes Management provides practical recommendations to help improve the care of patients with type 1 diabetes.