In diabetic ketoacidosis brain injury including cerebral oedema and infarction is caused by interleukin-1

Abstract

BackgroundBrain injury in diabetic ketoacidosis (DKA) is common but under recognized and affects up to 54% of patients with this complication. It’s manifestations include cerebral oedema (CE) and cerebral infarction (CI). The etiology of CE in DKA has up to the present time been uncertain. Practical management had been guided by the assumption that rapid osmotic shifts due to rapid correction of hypovolemia and reduction of plasma glucose could cause a shift of water into the cells. The osmotic effect of glucose can cause inflammation by activation of inflammasomes. Recently it has been recognized that the body is in a pro-inflammatory state during DKA involving interleukin-1 production by inflammasomes. Interleukin-1 has been involved in the pathogenesis of cerebral oedema and CI. HypothesisIn diabetic ketoacidosis brain injury including cerebral oedema and infarction is caused by interleukin-1. Confirmation of hypothesis and implicationsInflammasome activity could be quantified in peripheral blood mononuclear cells and in patients with and without clinical and/or subclinical CE and/or stroke or features of cerebral ischemia on MRI. Surrogates of brain injury in peripheral blood like neuron specific enolase could be measured and correlated with inflammasome activity. Interleukin-1 receptor antagonists and inflammasome inhibitors including telmisartan could be assessed in their effect on MRI changes consistent with CE or CI in patients with DKA in randomised placebo-controlled trials.