<p>Correlation of acidosis-adjusted potassium level and cardiovascular outcomes in diabetic ketoacidosis: a systematic review</p>

Abstract

Background During the progress and resolution of a diabetic ketoacidosis (DKA) episode, potassium levels are significantly affected by the extent of acidosis. However, none of the current guidelines take into account acidosis during resuscitation of potassium level in DKA management, which may increase the risk of cardiovascular adverse events. Objective To assess literature regarding the adjustment of potassium level using pH to calculate pH-adjusted corrected potassium level, and to observe the relationship of cardiovascular outcomes with reported potassium level and pH-adjusted corrected potassium in DKA. Methodology Seven databases were searched from inception to January 2018 for studies which had reported people with diabetes developing diabetic ketoacidosis, in relation to prevalence or incidence, fluid resuscitation or potassium supplementation treatment, treatment or cardiovascular outcomes, and experimentation with DKA management or insulin. Quality of studies was evaluated using Cochrane Risk of Bias and Newcastle Ottawa Scale. Results Forty-seven studies were included in qualitative synthesis out of a total of 10,292 retrieved studies. Forty-one studies discussed the potassium level and blood pH at the time of admission, ten studies discussed cardiovascular outcomes, and only four studies concurrently discussed potassium level, pH, and cardiovascular outcomes. Only two studies were graded as good on the Newcastle Ottawa Scale. The reported potassium level was well within normal range (5.8 mmol/L), whereas pH rendered patients to be moderately acidotic (7.13). Surprisingly, none of the included studies mentioned pH-adjusted corrected potassium level and, hence, this was calculated later. Although mean corrected potassium was within the normal range (3.56 mmol/L), 13 studies had corrected potassium below 3.5 mmol/L and five had it below 3.0 mmol/L. Nevertheless, with the exception of one study, none discussed cardiovascular outcomes in the context of potassium or pH-adjusted potassium level. Conclusion The evidence surrounding cardiovascular outcomes during DKA episodes in light of a pH-adjusted corrected potassium level is scarce. A prospective observational, or preferably, an experimental study in this regard will ensure we can modify and enhance safety of existing DKA treatment protocols.

Diabetic Ketoacidosis Management and Treatment Outcome at Medical Ward of Shashemene Referral Hospital, Ethiopia: A Retrospective Study

“…Because almost all of the patients need potassium supplementation, due to Insulin or acidosis induced potassium exchange between extracellular and intracellular. 27 Indeed, study confirmed that around 22.7% of DKA patients at admission present with hypokalemia, 22 thus, the addition of insulin therapy will exacerbate the condition to be in more severe hypokalemia. 28,29 In addition, a study from the UK confirmed that patients treated for DKA had hypoglycemia in 27.6% and hypokalemia in 55%.…”

“…Insulin therapy was generally administered according to Ethiopian Standard Treatment Guidelines for DKA management. 26 The dose could possibly depend on the physicians' 27 Indeed, study confirmed that around 22.7% of DKA patients at admission present with hypokalemia, 22 thus, the addition of insulin therapy will exacerbate the condition to be in more severe hypokalemia. 28,29 In addition, a study from the UK confirmed that patients treated for DKA had hypoglycemia in 27.6% and hypokalemia in 55%.…”

“… 12 , 24 , 25 , 30 - 32 The most probable reason for such a high mortality rate could be due to lack of appropriate diabetic care, lack of screening for hypoglycemia and hypokalemia, financial constraints for laboratory support and insulin, as well as poor management practice of co-morbidity treatment like hypokalemia and hypoglycemia. 27 - 29 Therefore, in developing countries like Ethiopia, there should be free health care for those patients with DM to improve access to quality care.…”

Manejo de la Cetoacidosis Diabética en un hospital universitario de Montevideo en el período Junio - Setiembre de 2015.

“…En pacientes con CAD los niveles de potasio corporal total tienen un déficit de 3-5 mEq/ kg, sin embargo los niveles de potasio séricos usualmente son normales o incluso elevados, debido a la salida del potasio intracelular inducida por la hipertonicidad, deficiencia de insulina y acidosis (5). Cieluch y cols evaluaron la adherencia al protocolo de reposición de potasio y su relación con la duración de la CAD en 242 pacientes y demostraron que la no adherencia al protocolo ocurrió en 71% de los pacientes y se asoció significativamente a mayor duración de la CAD y a mayor volumen de potasio transfundido (16) .…”

Starvation ketoacidosis during prolonged fasting of 26 days

“…Elle se définit par une réduction de l'apport calorique, une diminution de la glycémie, la présence d'une cétonurie et d'une élévation des corps cétoniques sanguins avec prédominance du ␤-hydroxybutyrate. En dehors d'un jeûne prolongé, les autres étiologies d'acidocétose sont [1][2][3][4][5][6][7] : -l'acidocétose alcoolique (perturbation de la balance NADH/NAD + par métabolisation de l'éthanol via l'alcool et l'aldéhyde déshydrogénase) ; -l'acidocétose diabétique (déficit énergétique causé par l'insulinopénie) ; -la cétose de jeûne chez la femme enceinte et chez la femme allaitante ; -les causes iatrogènes (acidocétose euglycémique et complication des inhibiteurs de SGLT-2 ; glucocorticoïdes, neuroleptiques par exemple) ; -certaines maladies héréditaires du métabolisme (notamment aciduries organiques en décompensation, déficit de la cétolyse, cytopathies mitochondriales). La figure 1 synthétise les étiologies présentées et les mécanismes biochimiques menant à l'acidocétose.…”