Higher Bicarbonate Levels Research Articles

Sudden Cardiac Arrest Associated with Hemodialysis: A Community-Based Study.

Individuals with end-stage renal disease may be at increased risk of sudden cardiac arrest (SCA) associated with dialysis therapy. However, community-based studies with comprehensive adjudication of SCA are lacking. We conducted a community-based study using a case-case study design in a US population of ≈1 million. All SCA cases with chronic kidney disease (CKD) were ascertained prospectively (2002-2020). We reviewed EMS narratives and archived medical records from regional hospitals to capture patients dialysis history, schedules, and the timing of SCA events in relation to dialysis sessions. Among those on regular hemodialysis, individuals who suffered SCA during hemodialysis or within an hour after completing hemodialysis (Intradialytic/immediate post-HD [IIHD]) were compared to cases with SCA at other times (non-IIHD). Non-compliant individuals or those intolerant of dialysis were excluded. Out of 1,023 SCA cases with CKD, 195 (19.1%) were undergoing regular scheduled hemodialysis. Among these cases, 24.1% were IIHD SCA, while 75.9% occurred non-IIHD. The incidence of SCA during dialysis was 2.9 times higher than expected by chance. SCA events were more likely to occur on dialysis days (65.3% of events) vs. 34.7% events on the 4 off dialysis days (p<0.001). IIHD SCA had higher serum sodium (138.9±4.8 vs. 135.5±5.5 mmol/L, p=0.005), lower serum potassium (3.6±0.7 vs. 5.6±1.6 mmol/L, p<0.001), and higher bicarbonate levels (25.9±6.6 vs. 20.2±5.5 mmol/L, p<0.001) compared to their non-IIHD SCA counterparts. Regarding resuscitation details, IIHD SCA had a higher percentage of shockable rhythm (46.5 vs. 32.4%, p=0.09), witnessed collapse (85.1 vs. 53.4%, p<0.001), bystander CPR (72.3 vs. 37.9%, p<0.001), return of spontaneous circulation (66.0 vs. 42.5%, p=0.005), and survival to hospital discharge (30.4 vs. 5.4%, p<0.001) compared to non-IIHD SCA. In patients undergoing dialysis, SCA events were significantly more common on dialysis days, and 3-fold higher than expected by chance. We identified potential risk factors and survival outcome differences between IIHD vs. non-IIHD SCA groups that warrant future investigation.

Respiratory Syncytial Virus Infections in Pediatric Intensive Care: Association of Sociodemographic Data and Clinical Outcomes with Viral and Bacterial Co-infections.

The aim of the study was to evaluate respiratory syncytial virus (RSV) infections in cases followed in the pediatric intensive care unit (PICU). The study was designed as a prospective cohort in 6 PICUs. There were 3 groups: only RSV (+), RSV (v+) who were positive for another viral agent(s) in addition to RSV, and RSV (b+) who were positive for a bacterial agent(s) in addition to RSV. A total of 119 cases were included in the study, 67 (56.3%) of whom were male. The RSV (+) group had a lower pH compared to the other groups and a higher rate of acute bronc hiolitis/bronchitis diagnoses compared to the RSV (v+) group. The RSV (v+) group had higher bicarbonate levels, higher creatinine levels, longer hospital stays, and higher Pediatric Risk of Mortality-3 scores (PRISM-3) compared to the RSV (+) group. Cases with RSV (b+) were younger and also had lower body weight compared to the other groups. Furthermore, the RSV (b+) group had higher C-reactive protein and Procalcitonin (PCT) levels and higher rates of High Flow Nasal Cannula-Oxygen Therapy (HFNC-OT) use. Multiple linear regression analysis revealed that PRISM-3 score, PCT levels, Pediatric Acute Respiratory Distress Syndrome diagnoses, inhaled steroid use, chronic illness status, and heart rate on admission were associated with the length of stay in the PICU. High flow nasal cannula-oxygen therapy continues to be the most frequently preferred respiratory support method in RSV infections. Viral infections accompanying RSV can increase the severity of the disease.

Iron Toxicity in Plants: A Review

Iron (Fe) is an essential micronutrient for plant growth and development. However, increased absorption of iron leads to iron toxicity. This leads to damage to plant cell membranes, decreased growth, productivity, and thus general health. The presence of free iron in cells can lead to an imbalance Redox in cells Pro-oxidant state, thus generating oxidative stress. In plants, iron is involved in chlorophyll synthesis, and is therefore essential for maintaining the structure and function of chloroplasts. Micronutrients in the soil can limit plant growth, even if all other nutrients are available in sufficient quantities. Micronutrient deficiencies are widespread due to the nature of the soil, high pH, low organic matter, salt stress, and persistent drought. High levels of bicarbonate in irrigation water, as well as unbalanced use of fertilizers. Iron (Fe) toxicity is a widespread nutritional disorder. It grows in acidic, sulphurous soils, as well as low sandy soils (i.e. iron is easily reducible) that contain a high percentage of organic matter. Iron toxicity can be reduced by using rice that is tolerant to high levels of iron.

Effects of bicarbonate on antioxidant, immune, osmolytic and metabolic capabilities of Scylla paramamosain

Effects of bicarbonate on antioxidant, immune, osmolytic and metabolic capabilities of Scylla paramamosain

#2507 Enhancing critical care nephrology: analyzing continuous renal replacement therapy with a citrate-based anticoagulation focus

Abstract Background and Aims Continuous renal replacement therapy (CRRT) is pivotal for managing acute kidney injury (AKI) unstable patients. However, questions persist regarding prescription and the role of anticoagulation. This study aims to examine CRRT practices, focus on citrate-based anticoagulation and clarify contraindications. Method This study comprises a retrospective analysis of a patient cohort requiring CRRT and admitted to the Postoperative Intensive Care Unit and Burn Unit. Inclusion criteria involved the need for CRRT and adult age, with exclusion criteria based on treatment duration (&amp;lt;48 hours), reducing the initial cohort from 256 to 176 patients. Clinical variables, including gender, age, underlying pathology, CRRT modality, and anticoagulation type, were characterized. Subsequently, the association between anticoagulation type and clot formation within 48 hours and in-hospital mortality was investigated. Furthermore, an analysis of citrate-based CRRT was conducted, evaluating laboratory values (Table 1) at the beginning and 48 hours using the Wilcoxon test, and their correlation with clot development and mortality. Additionally, we used a logistic regression model to explore the relationship between AST, ALT, and lactate values with citrate accumulation. Finally, a survival analysis was conducted. Results The sample consisted of 66.5% males and 33.5% females, with an average age of 59.48 years. Reasons for admission are depicted in Fig. 1. CRRT modalities were 20.5% HDVVC, 76.1% HDFVVC, and 3.4% HFVVC. Anticoagulation included 35.2% none, 28.4% heparin, 33.5% citrate, and 2.8% alprostadil. Filter clotting occurred in 29.1% withing 48 hours. Heparin was associated with a 5.4-fold increased risk of clotting compared to citrate. Mortality was 63.3%, with no anticoagulation type showing a significant association. Parameters at CRRT initiation and 48 hours for citrate-based CRRT patients and Wilcoxon test results are presented in Table 1. Only 5.1% had filter clotting &amp;lt;48 hours, and no baseline parameters were significantly associated with an increased clotting risk. There was one case of citrate intoxication due to a programming error, which was not included. 76.81% had CaT/CaI &amp;lt;2.1, and 7.25% had CaT/CaI &amp;gt;2.1, requiring technique adjustments. Aminotransferases and lactate values, often considered as contraindications for citrate, were analyzed: The average AST and ALT values were 188.53 IU/l and 108.08 IU/l, respectively. When AST levels exceeded 5 times the normal range and ALT levels exceeded 3 times the normal range, a statistically significant association with CaT/CaI &amp;gt;2.1 at the 48-hour mark of CRRT utilization was observed (p &amp;lt; 0.001 for both).The average lactic acid value was 1.74 mg/dl. Having a lactic acid level &amp;gt;4 was associated (p &amp;lt; 0.05) with a higher risk of developing CaT/CaI &amp;gt;2.1. 54.2% of the sample died. No baseline parameters were significantly associated with it. At 48 hours, higher bicarbonate levels and metabolic alkalosis were associated with increased mortality (p &amp;lt; 0.05). The median survival time was 11 days (±4.38). Conclusion This study supports the use of citrate-based anticoagulation in CRRT, as no cases of citrate intoxication (CaT/CaI &amp;gt;2.5) were found. Nonetheless, a significantly elevated AST (&amp;gt;5 times normal), ALT (&amp;gt;3 times normal), and lactate (&amp;gt;4 mg/dl), were associated with a higher risk of citrate accumulation (CaT/CaI &amp;gt;2.1). Customized approaches and preventive measures to mitigate the development of metabolic alkalosis are essential for optimizing patient outcomes.

Serum bicarbonate levels and kidney outcomes in critically ill patients: a prospective cohort study.

The interplay between serum bicarbonate levels and kidney outcomesis not fully understood. We conducted a prospective cohort study in three intensive care units (ICUs) to evaluate the association of serum bicarbonate levels with acute kidney injury (AKI) and kidney function recovery in critically ill patients. A prospective cohort study in three intensive care units (ICUs) was performed. The serum bicarbonate level in the first 24h after ICU admission was categorized as low (< 22mEq/L), normal (22-26mEq/L), or high (> 26mEq/L). Serum creatinine (SCr) levels according to theKDIGOAKI guideline were used for defining AKIwithin the first 7 days of ICU stay. At ICU admission, SCr≥ 1.1for women and ≥ 1.3 mg/dL for men were indicative of impaired kidney function.Mortality outcome was tracked up to 28days, and kidney function recovery was assessed at hospital discharge. A total of 2732 patients (66 ± 19years and 55% men) were analyzed, with 32% having impaired kidney functionat ICU admission. Overall, 26% of patients had low bicarbonate levels, while 32% had high bicarbonate levels. Notably, patients with preserved kidney function showed a lower prevalence of low bicarbonate levels compared to those with impaired kidney function (20% vs. 39%, p < 0.001), while higher rates were observed for high bicarbonate (35% vs. 24%, p < 0.001). Compared with patients with normal serum bicarbonate levels, those with low bicarbonate were 81% more likely to develop AKI (OR = 1.81; 95% CI 1.10-2.99), whereas those with high bicarbonate were 44% less likely (OR = 0.56; 95% CI 0.32-0.98) in the adjusted model for confounders. Neither those with high nor low serum bicarbonate levels were associated with an increased risk of mortality (HR = 1.03; 95% CI 0.68-1.56 and 0.99; 95% CI 0.68-1.42, respectively). In subgroup analysis, regardless of the kidney functionat ICU admission, serum bicarbonate levels were not associated with the development of AKI and all-cause mortality. Regarding kidney function recovery, higher non-recovery rates were found for those with low bicarbonate. In critically ill ICU patients, low bicarbonate levels were associated with the more likely development of AKIand subsequentnon-recovery ofkidney function, while high bicarbonatelevels showed no such association. Therefore, low bicarbonate levels may be considered a risk factor for adverse kidney outcomes in critically ill patients.

Utility of Pyloric Length Measurement for Detecting Severe Metabolic Alkalosis in Infants with Hypertrophic Pyloric Stenosis.

Infantile hypertrophic pyloric stenosis (IHPS) is a common gastrointestinal disease in neonates and hypochloremia metabolic alkalosis is a typical laboratory finding in affected patients. This study aimed to analyze the clinical characteristics of infants with IHPS and evaluate the association of clinical and laboratory parameters with ultrasonographic findings. Infants diagnosed with IHPS between January 2017 and July 2022 were retrospectively evaluated. A total of 67 patients were included in the study. The mean age at diagnosis was 40.5±19.59 days, and the mean symptom duration was 11.97±9.91 days. The mean pyloric muscle thickness and pyloric canal length were 4.87±1.05 mm and 19.6±3.46 mm, respectively. Hyponatremia and metabolic alkalosis were observed in five (7.5%) and 36 (53.7%) patients, respectively. Serum sodium (p=0.011), potassium (p=0.023), and chloride levels (p=0.015) were significantly lower in patients with high bicarbonate levels (≥30 mmol/L). Furthermore, pyloric canal length was significantly higher in patients with high bicarbonate levels (p=0.015). To assess metabolic alkalosis in IHPS patients, the area under the receiver operating characteristic curve of pyloric canal length was 0.910 and the optimal cutoff value of the pyloric canal length was 23.5 mm. We found a close association between laboratory and ultrasonographic findings of IHPS. Clinicians should give special consideration to patients with pyloric lengths exceeding 23.5 mm and appropriate fluid rehydration should be given to these patients.

Factors associated with mortality of patients with COVID-19 on invasive mechanical ventilation: A retrospective cohort study in a university hospital in Northeastern Brazil.

The aim of this study is to identify the factors associated with mortality in patients with COVID-19 undergoing invasive mechanical ventilation at a university hospital in Northeastern Brazil. This is a retrospective cohort from April to August 2020 through an analysis of medical records, considering the demographic profile, comorbidities, complications, supports, respiratory and laboratory parameters. A total of 65 patients required invasive mechanical ventilation, of which 64.6% died in the ICU. They were older, had more comorbidities, shorter length of stay in the intensive care unit, received more support such as palliative care and two vasopressors simultaneously, showed lower levels of pH, hemoglobin and calcium, and higher levels of bicarbonate, lactate, prothrombin time, international normalized ratio, troponin and ferritin at the start of invasive mechanical ventilation. Furthermore, the time course of pH, arterial oxygen partial pressure to fractional inspired oxygen ratio, arterial carbon dioxide partial pressure, lactate, hemoglobin, platelets, lymphocytes, neutrophil-to-lymphocyte ratio, coagulation parameters, calcium, urea, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, ferritin, static compliance, airway resistance, tidal volume, and noradrenaline doses showed association with mortality. There was a high mortality rate in invasively mechanically ventilated COVID-19 patients, with some associated factors identified at the start of invasive mechanical ventilation and others identified over time.

Factors associated with carbon dioxide transfer in an experimental model of severe acute kidney injury and hypoventilation during high bicarbonate continuous renal replacement therapy and oxygenation membrane support.

To investigate the factors influencing carbon dioxide transfer in a system that integrates an oxygenation membrane in series with high-bicarbonate continuous veno-venous hemodialysis in hypercapnic animals. In an experimental setting, we induced severe acute kidney injury and hypercapnia in five female Landrace pigs. Subsequently, we initiated high (40mEq/L) bicarbonate continuous veno-venous hemodialysis with an oxygenation membrane in series to maintain a pH above 7.25. At intervals of 1 hour, 6 hours, and 12 hours following the initiation of continuous veno-venous hemodialysis, we performed standardized sweep gas flow titration to quantify carbon dioxide transfer. We evaluated factors associated with carbon dioxide transfer through the membrane lung with a mixed linear model. A total of 20 sweep gas flow titration procedures were conducted, yielding 84 measurements of carbon dioxide transfer. Multivariate analysis revealed associations among the following (coefficients ± standard errors): core temperature (+7.8 ± 1.6 °C, p < 0.001), premembrane partial pressure of carbon dioxide (+0.2 ± 0.1/mmHg, p < 0.001), hemoglobin level (+3.5 ± 0.6/g/dL, p < 0.001), sweep gas flow (+6.2 ± 0.2/L/minute, p < 0.001), and arterial oxygen saturation (-0.5 ± 0.2%, p = 0.019). Among these variables, and within the physiological ranges evaluated, sweep gas flow was the primary modifiable factor influencing the efficacy of low-blood-flow carbon dioxide removal. Sweep gas flow is the main carbon dioxide removal-related variable during continuous veno-venous hemodialysis with a high bicarbonate level coupled with an oxygenator. Other carbon dioxide transfer modulating variables included the hemoglobin level, arterial oxygen saturation, partial pressure of carbon dioxide and core temperature. These results should be interpreted as exploratory to inform other well-designed experimental or clinical studies.

Calcium carbide-ripened plantain induced alterations in plasma electrolytes concentration and kidney function in rats.

Artificial fruit ripening agents such as ethanol, ethylene, ethephon, and calcium carbide (CaC2) is usually employed in stimulating the fruit ripening process. Currently, there is a paucity of information regarding the effects of various artificial fruits ripening methods on the health status of consumers. In this study, the physiological effects and possible health hazards associated with the consumption of plantain ripened by CaC2 and other non-chemical methods on the kidneys were investigated. Artificially ripened plantain was mixed with rat feed and fed to Wistar albino rats for four weeks, and the levels of plasma electrolytes (Na+, HCO3-, K+, and Cl-), urea, creatinine, as well as histological changes in the kidneys were determined. Results indicated that rats fed with carbide-ripened plantain had a significantly high level of plasma bicarbonate (HCO3-) compared to control rats., but there was no difference in the level of plasma sodium (Na+). However, the levels of plasma potassium (K+) and chloride (Cl-) were significantly low in rats fed with CaC2-ripened plantain as compared to the control rats. Furthermore, the levels of urea and creatinine were significantly high in rats fed with CaC2-ripened plantain compared to the control animals. Histological analyses showed glomeruli atrophy and tubular necrosis in kidneys of rats fed with CaC2-ripened plantain, thereby further indicating toxicity to the kidneys. Histological evidence and alterations in the level of the plasma electrolytes, urea, and creatinine suggest that consumption of fruits ripened with calcium carbide may be harmful to the kidneys.

High-flow nasal cannula may prolong the length of hospital stay in patients with hypercapnic acute COPD exacerbation

High-flow nasal cannula (HFNC) is increasingly used in patients with acute exacerbation of COPD (AECOPD). We aimed to confirm whether the baseline bicarbonate is an independent predictor of outcomes in patients with hypercapnic AECOPD receiving HFNC. This was a secondary analysis of a multicentre randomised trial that enrolled 330 patients with non-acidotic hypercapnic AECOPD supported by HFNC or conventional oxygen treatment (COT). We compared the length of stay (LOS) in hospital and the rate of non-invasive positive pressure ventilation (NPPV) use according to baseline bicarbonate levels using the log-rank test or Cox proportional hazard model. In the high bicarbonate subgroup (n=165, bicarbonate 35.0[33.3-37.9] mmol/L, partial pressure of arterial carbon dioxide [PaCO2] 56.8[52.0-62.8] mmHg), patients supported by HFNC had a remarkably prolonged LOS in hospital when compared to COT (HR 1.59[1.16-2.17], p=0.004), whereas patients in the low bicarbonate subgroup (n=165, bicarbonate 28.8[27.0-30.4] mmol/L, PaCO2 48.0[46.0-50.0] mmHg) had a comparable LOS in hospital regardless of respiratory support modalities. The rate of NPPV use in patients with high baseline bicarbonate level was significantly higher than that in patients with low baseline bicarbonate level (19.4% vs. 3.0%, p<0.0001). Patients with high bicarbonate level in HFNC group had a lower rate of NPPV use compared to COT group (15.4% vs. 23.0%, p=0.217). Among patients with non-acidotic hypercapnic AECOPD with high baseline bicarbonate level, HFNC is significantly associated with a prolonged LOS in hospital, which may be due to the reduced escalation of NPPV treatment. clinicaltrials.gov (NCT03003559).

Arrhythmias in Critically Ill Surgical and Non-surgical Patients: A National Propensity-Matched Study.

Arrhythmias are common in critically ill patients, though the impact of arrhythmias on surgical patients is not well delineated. We aimed to characterize mortality following arrhythmias in critically ill patients. We performed a propensity-matched retrospective analysis of intensive care unit (ICU) patients from 2007 to 2017 in the Cerner Acute Physiology and Chronic Health Evaluation database. We compared outcomes between patients with and without arrhythmias and those with and without surgical indications for ICU admission. We also modeled predictors of arrhythmias in surgical patients. 467,951 patients were included; 97,958 (20.9%) were surgical patients. Arrhythmias occurred in 1.4% of the study cohorts. Predictors of arrhythmias in surgical patients included a history of cardiovascular disease (odds ratio [OR] 1.35, 95% confidence interval [CI95] 1.11-1.63), respiratory failure (OR 1.48, CI95 1.12-1.96), pneumonia (OR 3.17, CI95 1.98-5.10), higher bicarbonate level (OR 1.03, CI95 1.01-1.05), lower albumin level (OR 0.79, CI95 0.68-0.91), and vasopressor requirement (OR 27.2, CI95 22.0-33.7). After propensity matching, surgical patients with arrhythmias had a 42% mortality risk reduction compared to non-surgical patients (risk ratio [RR] 0.58, CI 95 0.43-0.79). Predicted probabilities of mortality for surgical patients were lower at all ages. Surgical patients with arrhythmias are at lower risk of mortality than non-surgical patients. In this propensity-matched analysis, predictors of arrhythmias in critically ill surgical patients included a history of cardiovascular disease, respiratory complications, increased bicarbonate levels, decreased albumin levels, and vasopressor requirement. These findings highlight the differential effect of arrhythmias on different cohorts of critically ill populations.

Unexpected cause of recurrent diabetic ketoacidosis in type 1 diabetes: a case report

BackgroundGastrointestinal (GI) symptoms are commonly observed in patients with diabetic ketoacidosis (DKA), which usually resolves completely with therapy. However, GI symptoms can persist after DKA resolves, which can pose diagnostic and management challenges for physicians, especially when dealing with an exceptional diagnosis such as cannabinoid hyperemesis syndrome (CHS).Case presentationIn this case report, we present a patient with type 1 diabetes who had been treated for DKA 6 times in the past year and was eventually diagnosed with CHS.ConclusionIn conclusion, this case demonstrates that a presumptive and incorrect diagnosis can mislead physicians, especially when dealing with challenging diagnoses. Therefore, patients with type 1 diabetes with unusual presentations, such as unexpectedly high pH and bicarbonate levels, with hyperglycemic ketosis should be screened for illicit drug use, especially cannabis.

#4141 SERUM BICARBONATE AND CKD PROGRESSION: A LONGITUDINAL ANALYSIS BY THE GROUP-BASED TRAJECTORY MODEL

Abstract Background and Aims Follow-up studies in CKD patients showed an inverse relationship between serum bicarbonate and CKD progression, but only sparse longitudinal observations testing this relationship exist. Bicarbonate supplementation slowed the progression rate of CKD in 5 trials, but no such effect was registered in six trials. All these trials had limited power and were at high risk of bias. In the lack of well-designed clinical trials with sufficient power, longitudinal studies provide circumstantial new evidence for the hypothesis that bicarbonate supplements can mitigate the risk of adverse kidney outcomes. Methods We performed a longitudinal study in a cohort of 528 patients with at least 3 longitudinal measurements of bicarbonate over 32 months (inter-quartile range 30 – 36 months). The association between bicarbonate trajectories over time and the incidence rate of renal events (&amp;gt;30% eGFR reduction, dialysis or transplantation) were investigated by a two stages analysis: 1) in the first stage, we identified distinctive group-based bicarbonate trajectories analysis (GBTM, Annu Rev Clin Psychol. 2010;6:109-38); 2) in the second stage we assessed the association between bicarbonate trajectories groups and the risk of renal events by Cox proportional hazard model. Results One hundred and twenty-six patients had renal events on longitudinal observation. Four distinct trajectories of bicarbonate (based on intercept) were identified and labelled as low trajectory [including 11% of patients, mean (± SD) bicarbonate: 19.07± 2.5 mEq/L], moderate [35% of patients, bicarbonate: 21.2± 2.3 mEq/L], moderate-high [42% of patients, bicarbonate: 25.1± 2.2 mEq/L] and high [including 12% of patients, bicarbonate: 27.9± 2.8 mEq/L]. In analyses adjusting for age, gender, smoking, diabetes, total cholesterol, systolic BP, background CV comorbidities, anti-hypertensive drugs, haemoglobin, albumin, phosphate, hs-CRP, 24h proteinuria, and eGFR, the hazard rate (HR) of renal events decreased in a dose-dependent fashion from the lowest bicarbonate trajectory (reference category, HR 1) to the moderate (HR:0.70, 95%CI 0.43-1.14), high moderate (HR:0.54, 95%CI 0.31-0.93), and high bicarbonate category (HR:0.31, 95%CI 0.12-0.80) (P for trend=0.005). Thus, for patients in the high bicarbonate category (27.9± 2.8 mEq/L), there is an 69% risk reduction for a renal composite endpoint. Conclusion In a longitudinal analysis of a cohort of CKD patients, high bicarbonate levels are associated with a substantially reduced risk of renal events. These findings represent a strong call for well-designed, adequately powered randomised trials testing the effect of bicarbonate supplements or pharmacologic interventions that increase serum bicarbonate on renal outcomes. Given the substantial risk reduction in patients in the highest bicarbonate trajectory, these trials are an absolute clinical research priority.

Undiagnosed hypoglycaemia disorders in children detected when hypoglycaemia occurs in the setting of illness: a retrospective study

ObjectiveWhether hypoglycaemia incidentally detected during intercurrent illness in children requires an endocrine workup remains controversial. This study aimed to determine the yield of conducting a diagnostic evaluation in this setting...

Pseudo-Bartter syndrome in an infant without obvious underlying conditions: A case report

Pseudo-Bartter syndrome (PBS) develops owing to renal or extrarenal chloride loss, leading to hypokalemic alkalosis. Whereas most adult cases result from diuretic/laxative abuse, many infantile cases occur secondary to cystic fibrosis. Rarely, infantile PBS is caused by renal salt loss with anomalies of the kidney/urinary tract or genetic disorders, such as Dent disease. Here, we report the case of a 10-mo-old girl with a one-month history of decreased formula intake and 5.6% body weight loss. She showed typical laboratory findings as PBS, including hypokalemia (2.7 mEq/L) and high levels of bicarbonate (32.7 mEq/L) with a plasma renin activity of 399 ng/mL/h. With minimum supplementation of potassium and sodium, an improvement in body mass index, from –1.13 SD to +0.52 SD, with complete resolution of laboratory data was obtained in approximately one month. No causative mutations were identified in candidate genes for Bartter–Gitelman syndrome. Due to profound hypochloruria (< 15 mEq/L), PBS of renal origin was unlikely. In addition, extrarenal chloride loss did not seem to be the case, because the patient never manifested gastrointestinal symptoms. Therefore, we speculate that a temporary decrease in chloride intake, coupled with the putative genetic/epigenetic disadvantage of chloride retention, such as a subtle renal leak, may be responsible for the PBS in our patient.

A case report of a COPD patient presented in severe metabolic alkalosis

Chronic Obstructive Pulmonary Disease (COPD) patients generally present with respiratory acidosis and type 2 respiratory failure. Here we present a case of 65 years old female, who is a known case of COPD and presented in our emergency department with severe metabolic alkalosis (pH 7.730, HCO3- greater than 99.9mmol/l). She was referred from other center after the development of seizure. Urinary sodium was sent which indicated the cause of metabolic alkalosis was contraction alkalosis; we then treated the patient with IV fluids, antibiotics and Mechanical Ventilator. Arterial Blood gas analysis was initially done every 4 hours till the pH was corrected. After pH was corrected the patient was extubated to intermitted Non Invasive Ventilation (NIV) for type 2 respiratory failure. With pulmonary rehabilitation we could discharge the patient with inhalers; without the need for NIV or supplementary oxygen. This is one of the rare cases where the patient presented with a very high bicarbonate level, high partial pressure of carbon dioxide in arterial blood, and high pH. The patient was successfully managed with IV fluids and mechanical ventilation.

An Audit of Factors Impacting the Time to Resolution of the Metabolic Parameters in Diabetic Ketoacidosis Patients.

Diabetic ketoacidosis (DKA) is a major complication affecting patients with diabetes. It is often the first presentation of type I diabetes and can also occur due to a lack of compliance with insulin therapy or infection, among other causes. Hospitalizations for DKA have increased globally among patients with type I and type II diabetes, which poses a strain on health systems. To determine the factors impacting the time to resolution of metabolic parameters in DKA patients. This retrospective study was performed by reviewing the clinical records of hospitalized DKA patients at King Fahad Specialist Hospital, a tertiary-level healthcare center in Buraidah, Al Qassim region, Saudi Arabia. The study included all DKA admissions that met the inclusion criteria between September 2019 and April 2022. A total of 129 patients with a diagnosis of DKA from January 2019 to April 2022 were identified. Of these, 67 patients met the inclusion criteria. More females experienced DKA (56.7%), and the study population had an improvement rate of 97%. The mean length of stay (LOS) for patients with DKA was 73.19 hours, and the median time for DKA resolution was 15 hours (mean time 21.38 hours). The omission of insulin was the leading precipitating factor for DKA (43%) followed by infection (12%). A high serum bicarbonate (HCO3) level was identified as an independent predictor for a longer time to resolution. Patients with DKA who have high glucose levels on admission, higher body mass index (BMI), older age, and higher weight stayed in the hospital for extended periods. Conversely, patients with a higher serum potential of Hydrogen (pH) had a shorter LOS. Age was the only clinically independent predictor for a minimum LOS for DKA. Patients with comorbidities had a longer hospital LOS than patients without comorbidities; no such relationship has been reported in other studies. Patients in our study population had a longer time of resolution than observed in other studies, although no clear cause was identified. This study contributes to our understanding of DKA in hospitalized patients in Saudi Arabia. This is the first study to link patients with DKA who have comorbidities to a longer hospitalstay in the kingdom of Saudi Arabia. This study also identified multiple clinical and biochemical parameters related to the variability in LOS and time to resolution of DKA in hospitalized patients.

Combination of bicarbonate and low temperature stress induces the biosynthesis of both arachidonic and docosahexaenoic acids in alkaliphilic microalgae Dunaliella salina HTBS

High bicarbonate levels and low temperature may have an impact on microalgae cultivation. However, changes in cellular composition in response to the combination of the above stresses are still poorly understood. In this study, the combined effects of bicarbonate and low temperature on biochemical changes in alkaliphilic microalgae Dunaliella salina HTBS were investigated. Comparing to the control condition of 25°C without bicarbonate, the cell density was increased from 0.69 to 1.18 in the treatment condition of 0.15 M bicarbonate and low temperature (16 °C) while the lipid\protein\carbohydrate contents were increased from 34.71% to 43.94%, 22.44% to 26.03%, 22.62% to 29.18%, respectively. Meanwhile, the PUFAs, arachidonic acid (AA) and docosahexaenoic acid (DHA) contents reached to 3.52% and 4.73% with the combination of low temperature and bicarbonate, respectively, whereas they were not detected when the cells were treated with single condition. Moreover, both the chlorophyll and carotenoid contents were also detected with increased profiles in the combined treatments. As a result, the maximum photochemical efficiency but not reduced non-photochemical quenching was strengthened, which enhanced the photosynthetic performance. Additionally, our results indicated that D. salina HTBS could acclimate to the combined stress by up-regulating the activity of SOD\CAT and reducing MDA content. These findings demonstrated that the addition of a certain bicarbonate under low temperature could effectively enhance the biomass production and accumulation of AA and DHA, which would benefit the development of the microalgae industry in value-added products.

S3259 A Case of Propofol-Induced Acute Liver Failure

Introduction: Propofol is a parenteral anesthetic routinely used for procedures given its beneficial pharmacokinetic profile of rapid onset of action and reversal. Propofol drug toxicity is rare but has been associated with idiosyncratic acute liver injury in a small number of cases. To the best of our knowledge, we present the second case of propofol-induced acute liver failure (ALF) reported in literature. Case Description/Methods: An 88-year-old male with concern for gastrointestinal bleed underwent an upper endoscopy with propofol used as the anesthetic agent. The patient tolerated the endoscopy well with no hemodynamic compromise during or afterwards. No source of bleeding was identified so the plan was to proceed with a colonoscopy the next day. Shortly after the procedure, he was noted to have altered mental status. Evaluation with routine laboratory testing revealed elevated AST of 3248 IU/L and ALT of 2411 IU/L, both increased from 35 IU/L and 24 IU/L, respectively. He was also found to have high anion gap metabolic acidosis and bicarbonate level less than 9 mEq/L. His altered mentation continued to worsen, and he became hemodynamically unstable requiring transfer to the intensive care unit. He had no history of liver disease or excessive alcohol use, no risk factors for viral hepatitis, and took no medications known to cause liver injury. Work-up was unremarkable for acute and chronic liver disease. Propofol was ultimately surmised as the cause of ALF. Unfortunately, the patient’s mental status progressively worsened despite hemodynamic stabilization and normalization of liver enzymes. His family ultimately chose to transition to comfort measures and the patient passed soon after. Discussion: The incidence of drug-induced liver injury is increasing in developed countries and is a major etiology of ALF, accounting for greater than 50% of cases. Drug toxicity secondary to an idiosyncratic reaction is unpredictable and occurs infrequently in certain individuals. While propofol is generally considered a safe agent widely used for sedation, propofol-induced acute liver injury is a rare outcome. To the best of our knowledge, it is reported to have caused five cases of acute hepatitis and one other case of ALF. We report the second case of ALF due to propofol with a lethal outcome. We recommend close monitoring of patients treated with propofol for signs of hepatitis and that ALF due to a drug insult should be considered after common causes have been excluded.