Diabetic ketoacidosis, hyperosmolarity and hypernatremia: are high-carbohydrate drinks worsening initial presentation?

Abstract

The case of five pediatric patients who presented to the Royal Children's Hospital, Melbourne with newly diagnosed diabetes mellitus between January 2001 and September 2003 is reported. Each case was complicated by hyperosmolarity and hypernatremia and required intensive therapy. Fluid intake prior to admission in each case was documented and consisted of between 5 and 12 L of carbonated carbohydrate beverages and 'isotonic' sports drinks. At presentation, biochemical results of the four cases (four males and one female), mean age 13.6 yr (range 11.7-15.1 yr) included glucose (mean 1460 mg/dL; range 864-2106), adjusted sodium (mean 176.3 mmol/L; range 165-183), serum osmolarity (mean 399 mmol/kg; range 364-424), anion gap (mean 48 mEq/L; range 42-84), and pH (mean 7.15; range 7.01-7.27). All five cases had evidence of ketonuria on presentation. Treatment in all five cases consisted of replacement of fluids over a prolonged period of 72 h and careful monitoring of electrolyte response. Three of five cases required hemofiltration in the first 48 h postadmission. All five cases made a complete recovery without neurological sequelae. Carbonated carbohydrate fluid intake may precipitate a more severe presentation of type 1 diabetes mellitus (T1DM). Fluid composition and intake should be carefully estimated at admission to help identify and manage similar cases.

High Glucose and Ketosis (Acetoacetate) Increases, and Chromium Niacinate Decreases, IL-6, IL-8, and MCP-1 Secretion and Oxidative Stress in U937 Monocytes

“…Chromium-untreated cells were added buffer volume of 4 L. There was no change in pH of the medium-cells In this study, cells were exposed to a high glucose concentration of 35 mM to mimic diabetic conditions. Many previous studies have reported that glucose concentrations as high as 50 mM have been found in the blood of uncontrolled diabetic patients (13,40,44). It is true that blood glucose levels in patients are not likely to stay as high as 35 mM or hyperketonemic for 24 h. However, tissue damage in diabetic patients occurs over many years of countless hyperglycemic and/or ketotic episodes.…”

Role of hyperglycemia in the pathogenesis of Na+/K+ disturbance

“…Mc Donnell, et al, Kavelars, et al, and Hosen B reported high serum Na + level in hyperosmolar diabetes mellitus. 11,12 Nitzan and Zalmanovski showed hypernatraemia in glucose intolerant rats. 2 The development is associated with both -impairment of insulin-mediated glucose metabolism and glucagon-dependent glucose release.…”

Hydration and Disease

“…In children with diabetic ketoacidosis, the serum osmolality level on admission was the most important predictor of death [67]. In pediatric patients with newly diagnosed diabetes mellitus, high intakes of carbonated carbohydrate fluids favored a more severe presentation of ketoacidosis [68].…”