Keto-acidosis is usually associated with uncontrolled diabetes and typically poses few diagnostic problems when presenting as hyperglycaemia, metabolic acidosis and a high anion gap. An emaciated patient suffering from Duchenne Muscular Dystrophy and volume depletion presented with acidosis of unknown origin. Preliminary investigations appeared to rule out lactic acidosis, diabetic keto-acidosis and acidosis due to base loss. We have previously reported a technique utilizing liquid chromatography coupled to mass spectrometry (LC-MS) which can be used to characterize the underlying aetiology of acidosis and applied it to ultrafiltrate derived from a blood sample taken from this patient. The anion profile obtained on the chromatogram showed elevated levels of acetoacetate and hydroxybutyrate but no evidence of lactic acidosis, nor was the profile typical of that seen in 'unexplained' acidosis. We concluded that the patient was suffering from keto-acidosis associated with starvation and dehydration, the biochemical features being obscured by both the patient's chronic malnutrition and minimal muscle mass. A combination of enteral feeding and rehydration led to prompt resolution of the patient's metabolic acidosis.
"Third, a possible relationship has to be discussed between starvation ketoacidosis and the preexisting muscular dystrophy and glucosuria. Starvation ketoacidosis was described in two patients who were suffering from the Duchenne muscular dystrophy  . However, one patient had a history of type 2 diabetes, and the other had a long-lasting history of dysphagia and malnutrition. "
[Show abstract][Hide abstract] ABSTRACT: A 31-year-old pregnant woman (32 + 3 weeks) was admitted with extreme tachypnea. She had a previous history of congenital muscular dystrophy (Ullrich's disease) and isolated glucosuria. The patient had reduced food intake during the last 24 hours prior to admission and vomited twice. Serum glucose level was normal (112 mg/dL), while urinalysis revealed glucosuria 4+ and ketonuria 4+. ABG revealed pH 7.06, PCO2 9 mm Hg, and bicarbonate 2 mmol/L. Anion gap was 28 mmol/L. Tachypnea was a compensatory mechanism for a severe nonlactic metabolic acidosis. The diagnosis of starvation ketoacidosis was established. The patient received supplemental dextrose 10% intravenously and sodium bicarbonate. As fetal heart monitoring was pathological, an emergency caesarean section was performed. Umbilical cord venous pH was 7.01, with PCO2 34 mm Hg and bicarbonate 8 mmol/L. Starvation ketoacidosis is a rare metabolic disorder that may occur mainly in the third trimester of pregnancy. Muscular dystrophy and renal glucosuria were precipitating factors.
"The kidney plays a major role in acid-base regulation. Renal failure results in increasing levels of plasma organic acids and other unmeasured anions through continued fixed acid production of around 50 to 100 meq H+/day [67-69]. RRT plays a major role in acid-base regulation in two ways, firstly by removing metabolic acids and secondly by the net addition of sodium bicarbonate. "
[Show abstract][Hide abstract] ABSTRACT: Acute kidney injury is common in intensive care patients and continuous renal replacement therapy is the preferred treatment for this in most centres. Although these techniques have been adopted internationally, there remains significant variation with regard to their clinical application. This is particularly pertinent when one considers that the fundamental questions regarding any treatment, such as initiation, dose and length of treatment, remain a source of debate and have not as yet all been fully answered. In this narrative review we consider the timing of renal replacement therapy, highlighting the relative paucity of high quality data regarding this fundamental question. We examine the role of the usual biochemical criteria as well as conventional clinical indications for commencing renal replacement therapy together with the application of recent classification systems, namely RIFLE and AKIN. We discuss the potential role of biomarkers for acute kidney injury as predictors for the need for renal support and discuss commencing therapy for indications other than acute kidney injury.
[Show abstract][Hide abstract] ABSTRACT: This study investigates whether the strong ion gap (SIG) is associated with long-term outcome after cardiac arrest in patients treated with therapeutic hypothermia. The hypothesis of the study was that an elevated SIG was associated with unfavourable outcome after cardiac arrest.
Retrospective review of records from 1995 to 2007 of patients who received cardiopulmonary resuscitation.
Emergency department of a university hospital.
Patients who were successfully resuscitated after cardiac arrest (n = 288) and treated with mild therapeutic hypothermia.
Acid-base variables were calculated according to Stewart's approach, as modified by Figge and Fencl, and were determined immediately on admission and 12 h after the return of spontaneous circulation. Acid-base variables were determined at 37 degrees C and are reported without correction for patient temperature. Differences in SIG were compared between patients with favourable (survival 6 months with cerebral performance category 1 or 2) and unfavourable outcomes. SIG on admission and 12 h after return of spontaneous circulation was higher in patients with unfavourable outcome (n = 151; 52%). SIG 12 h after return of spontaneous circulation was identified as an independent predictor of outcome. A SIG > 8.9 mmol/L was associated with an increased cumulative hazard of death.
An elevated SIG 12 h after return of spontaneous circulation may be associated with unfavourable outcome in patients after cardiac arrest treated with mild therapeutic hypothermia. The unmeasured anions hidden behind an elevated SIG may represent markers of tissue damage.
Intensive Care Medicine 10/2008; 35(2):232-9. DOI:10.1007/s00134-008-1315-1 · 7.21 Impact Factor
Lanja Saleh, Daniel Mueller, Arnold von Eckardstein
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