Prolonged Acidosis Research Articles

Protein semisynthesis underscores the role of a conserved lysine in activation and desensitization of acid-sensing ion channels

Acid-sensing ion channels (ASICs) are trimeric ion channels that open a cation-conducting pore in response to proton binding. Excessive ASIC activation during prolonged acidosis in conditions such as inflammation and ischemia is linked to pain and stroke. A conserved lysine in the extracellular domain (Lys211 in mASIC1a) is suggested to play a key role in ASIC function. However, the precise contributions are difficult to dissect with conventional mutagenesis, as replacement of Lys211 with naturally occurring amino acids invariably changes multiple physico-chemical parameters. Here, we study the contribution of Lys211 to mASIC1a function using tandem protein trans-splicing (tPTS) to incorporate non-canonical lysine analogs. We conduct optimization efforts to improve splicing and functionally interrogate semisynthetic mASIC1a. In combination with molecular modeling, we show that Lys211 charge and side-chain length are crucial to activation and desensitization, thus emphasizing that tPTS can enable atomic-scale interrogations of membrane proteins in live cells.

Functional characterization of acid-sensing ion channels in the cerebellum-originating medulloblastoma cell line DAOY and in cerebellar granule neurons.

Acid-sensing ion channels (ASICs) are Na+ channels that are almost ubiquitously expressed in neurons of the brain. Functional ASIC1a is also expressed in glioblastoma stem cells, where it might sense the acidic tumor microenvironment. Prolonged acidosis induces cell death in neurons and reduces tumor sphere formation in glioblastoma via activation of ASIC1a. It is currently unknown whether ASICs are expressed and involved in acid-induced cell death in other types of brain tumors. In this study, we investigated ASICs in medulloblastoma, using two established cell lines, DAOY and UW228, as in vitro models. In addition, we characterized ASICs in the most numerous neuron of the brain, the cerebellar granule cell, which shares the progenitor cell with some forms of medulloblastoma. We report compelling evidence using RT-qPCR, western blot and whole-cell patch clamp that DAOY and cerebellar granule cells, but not UW228 cells, functionally express homomeric ASIC1a. Additionally, Ca2+-imaging revealed that extracellular acidification elevated intracellular Ca2+-levels in DAOY cells independently of ASICs. Finally, we show that overexpression of RIPK3, a key component of the necroptosis pathway, renders DAOY cells susceptible to acid-induced cell death via activation of ASIC1a. Our data support the idea that ASIC1a is an important acid sensor in brain tumors and that its activation has potential to induce cell death in tumor cells.

Revealing the arrangement of the intracellular termini of ASIC1a using transition metal ion FRET.

Acid-sensing ion channels (ASICs) are proton gated, sodium selective, trimeric ion channels primarily located in the central and peripheral nervous systems. Recently, it has been shown that the C-terminus of ASIC1a binds to the protein receptor interacting serine/threonine kinase 1 (RIPK1) under prolonged acidic conditions and this association triggers necroptotic cell death. It has been hypothesized that at neutral pH, the N- and C-termini interact which prevents the association of RIPK1 with the C-terminus. To test this, we performed microscale thermophoresis using a combination of peptides and purified proteins. We found that the ASIC1a C-terminus binds with high affinity to the RIPK1 death domain but does not bind to the ASIC1a N-terminus. We further investigated the proposed interaction of the ASIC1a N- and C-termini in intact channels in cell membranes using transition metal ion FRET (tmFRET) where we measure quenching of an incorporated small fluorophore unnatural amino acid 3-(6-acetylnaphthalen-2-ylamino)-2-aminopropanoic acid (L-Anap) by metal ions bound to a cysteine reactive chelator. First, we demonstrate that we are able to successfully incorporate L-ANAP at a number of positions in both the N- and C-termini of ASIC1a. Second, we measure tmFRET between multiple positions in the termini which show that the N- and C-termini are not in particularly close proximity and during acidosis they undergo only a small rearrangement that, in fact, moves them closer together. Given this result, we go on to map the topology and dynamics of these regions relative to metal ions incorporated into the plasma membrane via a lipid with an NTA head group. Our results suggest that there must be an alternative mechanism by which ASIC1a binds to RIPK1 only after prolonged acidosis.

Mechanistic insights into lipid regulation of the acid-sensing ion channels.

Acid-sensing ion channels are primary sensors of acidosis in the central and peripheral nervous systems. In this respect, ASICs have been implicated in a number of pathologic conditions where tissue acidosis occurs, including pain sensing during inflammation. Interestingly, although ASICs are activated by protons, the prolonged acidosis present in these conditions should render the channels inactive. One potential solution to this paradox is that, in addition to elevated concentration of protons, there are elevated endogenous inflammatory molecules that further potentiate the channel. Among the molecules elevated in inflammatory conditions are single acyl chain lipids like the polyunsaturated fatty acids (PUFAs). We have previously demonstrated a number of these lipids can stabilize the open state of ASICs, leading to a prolonged non-desensitizing activation, which in some cases can occur even at neutral pH. We found that this effect was dependent on a negatively charged head interaction with the outer transmembrane domain of the channel. However, a detailed understanding of the residues involved in this interaction and the mechanism by which lipids potentiate ASICs remain unknown. Here, we explore these open questions using patch-clamp electrophysiology. We find that lipid potentiation of the channel occurs in a state-dependent manner. We highlight isoform-dependent effects of lipid action on ASICs and use site-directed mutagenesis to narrow down key residues important in lipid binding. We examine lipid effects on the single channel parameters to determine how potentiation manifests at the whole-cell level. Finally, we test several potential mechanisms by which lipids potentiate, including the potential alteration of ionic concentrations at activation sites. Together, we build a model of the binding and mechanism of potentiation for an endogenous regulator of ASICs and provide a basis for future therapeutic development.

Acidosis induces RIPK1-dependent death of glioblastoma stem cells via acid-sensing ion channel 1a

Eliciting regulated cell death, like necroptosis, is a potential cancer treatment. However, pathways eliciting necroptosis are poorly understood. It has been reported that prolonged activation of acid-sensing ion channel 1a (ASIC1a) induces necroptosis in mouse neurons. Glioblastoma stem cells (GSCs) also express functional ASIC1a, but whether prolonged activation of ASIC1a induces necroptosis in GSCs is unknown. Here we used a tumorsphere formation assay to show that slight acidosis (pH 6.6) induces necrotic cell death in a manner that was sensitive to the necroptosis inhibitor Nec-1 and to the ASIC1a antagonist PcTx1. In addition, genetic knockout of ASIC1a rendered GSCs resistant to acid-induced reduction in tumorsphere formation, while the ASIC1 agonist MitTx1 reduced tumorsphere formation also at neutral pH. Finally, a 20 amino acid fragment of the ASIC1 C-terminus, thought to interact with the necroptosis kinase RIPK1, was sufficient to reduce the formation of tumorspheres. Meanwhile, the genetic knockout of MLKL, the executive protein in the necroptosis cascade, did not prevent a reduction in tumor sphere formation, suggesting that ASIC1a induced an alternative cell death pathway. These findings demonstrate that ASIC1a is a death receptor on GSCs that induces cell death during prolonged acidosis. We propose that this pathway shapes the evolution of a tumor in its acidic microenvironment and that pharmacological activation of ASIC1a might be a potential new strategy in tumor therapy.

Dynorphin Neuropeptides Decrease Apparent Proton Affinity of ASIC1a by Occluding the Acidic Pocket.

Prolonged acidosis, as it occurs during ischemic stroke, induces neuronal death via acid-sensing ion channel 1a (ASIC1a). Concomitantly, it desensitizes ASIC1a, highlighting the pathophysiological significance of modulators of ASIC1a acid sensitivity. One such modulator is the opioid neuropeptide big dynorphin (Big Dyn) which binds to ASIC1a and enhances its activity during prolonged acidosis. The molecular determinants and dynamics of this interaction remain unclear, however. Here, we present a molecular interaction model showing a dynorphin peptide inserting deep into the acidic pocket of ASIC1a. We confirmed experimentally that the interaction is predominantly driven by electrostatic forces, and using noncanonical amino acids as photo-cross-linkers, we identified 16 residues in ASIC1a contributing to Big Dyn binding. Covalently tethering Big Dyn to its ASIC1a binding site dramatically decreased the proton sensitivity of channel activation, suggesting that Big Dyn stabilizes a resting conformation of ASIC1a and dissociates from its binding site during channel opening.

GPR68 Contributes to Persistent Acidosis-Induced Activation of AGC Kinases and Tyrosine Phosphorylation in Organotypic Hippocampal Slices.

Persistent acidosis occurs in ischemia and multiple neurological diseases. In previous studies, acidic stimulation leads to rapid increase in intracellular calcium in neurons. However, it remains largely unclear how a prolonged acidosis alters neuronal signaling. In our previous study, we found that GPR68-mediated PKC activities are protective against acidosis-induced injury in cortical slices. Here, we first asked whether the same principle holds true in organotypic hippocampal slices. Our data showed that 1-h pH 6 induced PKC phosphorylation in a GPR68-dependent manner. Go6983, a PKC inhibitor worsened acidosis-induced neuronal injury in wild type (WT) but had no effect in GPR68−/− slices. Next, to gain greater insights into acid signaling in brain tissue, we treated organotypic hippocampal slices with pH 6 for 1-h and performed a kinome profiling analysis by Western blot. Acidosis had little effect on cyclin-dependent kinase (CDK) or casein kinase 2 activity, two members of the CMGC family, or Ataxia telangiectasia mutated (ATM)/ATM and RAD3-related (ATR) activity, but reduced the phosphorylation of MAPK/CDK substrates. In contrast, acidosis induced the activation of CaMKIIα, PKA, and Akt. Besides these serine/threonine kinases, acidosis also induced tyrosine phosphorylation. Since GPR68 is widely expressed in brain neurons, we asked whether GPR68 contributes to acidosis-induced signaling. Deleting GPR68 had no effect on acidosis-induced CaMKII phosphorylation, attenuated that of phospho-Akt and phospho-PKA substrates, while abolishing acidosis-induced tyrosine phosphorylation. These data demonstrate that prolonged acidosis activates a network of signaling cascades, mediated by AGC kinases, CaMKII, and tyrosine kinases. GPR68 is the primary mediator for acidosis-induced activation of PKC and tyrosine phosphorylation, while both GPR68-dependent and -independent mechanisms contribute to the activation of PKA and Akt.

P0145 / #1860: RISK FACTORS AND OUTCOMES OF ACUTE KIDNEY INJURY IN CHILDREN WITH DIABETIC KETOACIDOSIS IN PEDIATRIC INTENSIVE CARE UNIT AT A TERTIARY CARE CENTER

Aims & Objectives: To identify the risk factors and outcomes of Acute Kidney Injury (AKI) in children with Diabetic Ketoacidosis (DKA) admitted in PICU of a tertiary care hospital. Methods: We did a chart review of children aged 1 month to 17 years, admitted with a diagnosis of DKA in PICU between January, 2018- October, 2019. Data collection included demographic, clinical, laboratory and outcome related variables. AKI was defined as using Kidney Disease Improving Global Outcomes serum creatinine criteria. Data were analysed using Stata 11 software. Results: Out of 22 children admitted with DKA in PICU, 7 (31.8%) children developed AKI during the hospital stay. Among them, 6 (85.7%) had AKI at admission while one (14.3%) had AKI at 72 hours. 4 (57.1%) had AKI Stage 1, 2 (28.6%) had AKI Stage 2 and 1 (14.3%) had AKI stage 3. All 7 children with AKI recovered with hydration alone with median duration of recovery of 48 hrs (IQR-12, 192 hrs) without need of renal replacement therapy. Serum sodium at admission, pH and bicarbonate at 24 hours and presence of shock at admission were associated with AKI (p value<0.05 for all). Children with AKI had prolonged acidosis, increased need for mechanical ventilation, cerebral edema and longer PICU stay. However, AKI was not associated with increased mortality in our study. Conclusions: All children with AKI and DKA recovered with hydration alone. Serum sodium at admission, pH and bicarbonate at 24 hours and presence of shock at admission predicted AKI in children with DKA.

DEG/ENaC Ion Channels in the Function of the Nervous System: From Worm to Man.

DEG/ENaC channels are voltage-independent Na+/Ca2+ channels that are conserved across species and are expressed in many different cell types and tissues, where they contribute to a wide array of physiological functions from transepithelial Na+ transport, to sensory perception, and learning and memory. In this chapter, we focus on the members of this family that are expressed in the nervous system, grouping them based on their function. Structurally, DEG/ENaC channels are trimers formed by either identical or homologous subunits, each one protruding from the plasma membrane like a clenched hand. Crystallographic studies on chicken ASIC1a in the closed, inactivated, and open states revealed important details about the gating and permeation properties of these channels, and overall they show that the extracellular domain of the channel undergoes large conformational changes during gating. The vast majority of the channel's extracellular domain is conserved across different members and species; however, key changes including the insertion of extra loops near the finger and palm domains most likely confers gating specificity. Indeed, DEG/ENaC channels are gated by a wide range of stimuli, including mechanical forces, protons, and peptides, owing to the wide array of physiological functions they serve. Interestingly, DEG/ENaC channels are not only expressed in neurons but also in glia. Work in C. elegans is now beginning to shed new light on the role of glial DEG/ENaC in the function of the nervous system and suggests that they may be implicated in controlling ionic concentrations in the extracellular microenvironment. Finally, DEG/ENaC channels can become toxic and cause neuronal death when they are hyperactivated by genetic mutations or prolonged acidosis causing them to contribute to neuronal demise in stroke and ischemia. Taken together, molecular, structural, and behavioral work on DEG/ENaC channels expressed in the nervous system of different species highlights the crucial role of these channels in neuronal function. These data place DEG/ENaC channels in an excellent position for being considered as drug targets for the treatment of several neurological conditions and disorders from pain to epilepsy and ischemia.

Changes in meta-transcriptome of rumen epimural microbial community and liver transcriptome in young calves with feed induced acidosis

The common management practices of dairy calves leads to increased starch concentration in feed, which subsequently may cause rumen acidosis while on milk and during weaning. Until recently, few attempts were undertaken to understand the health risks of prolonged ruminal acidosis in post weaning calves. Resultantly, the molecular changes in the digestive tracts in post-weaning calves with ruminal acidosis remain largely unexplored. In this study, we investigated the liver transcriptome changes along with its correlation with the rumen microbial rRNA expression changes in young calves using our model of feed induced ruminal acidosis. In this model, new born calves were fed a highly processed, starch-rich diet starting from one week of age through 16 weeks. A total of eight calves were involved in this study. Four of them were fed the acidosis-inducing diet (Treated) and the rest of the four were fed a standard starter diet (Control). Liver and rumen epithelial tissues were collected at necropsy at 17 weeks of age. Transcriptome analyses were carried out in the liver tissues and rRNA meta-transcriptome analysis were done using the rumen epithelial tissues. The correlation analysis was performed by comparing the liver mRNA expression with the rumen epithelial rRNA abundance at genus level. Calves with induced ruminal acidosis had significantly lower ruminal pH in comparison to the control group, in addition to significantly less weight-gain over the course of the experiment. In liver tissues, a total of 428 differentially expressed genes (DEGs) (fold-change, FC ≥ 1.5; adjusted P ≤ 0.1) were identified in treated group in comparison to control. Biological pathways enriched by these DEGs included cellular component organization, indicating the impact of ruminal acidosis on liver development in young calves. Specifically, the up-regulated genes were enriched in acute phase response (P < 0.01), pyruvate metabolic process (P < 0.01) and proton-acceptors (P ≪ 0.001), indicating the liver’s response to feed induced acidosis at the transcriptome level. Twelve transferase activity related genes had significant correlation with rumen microbial rRNA expression changes. Among these genes, two up-regulated genes were reported with involvement in lipid metabolism in the liver, implying the direct effect of feed-induced acidosis on both the rumen microbial community and liver metabolism. Our study provides insight into the physiological remodeling in the liver resultant from the prolonged acidosis in post weaning calves, which may facilitate future RNA-seq based diagnosis and precision management of rumen acidosis in dairy calves.

Prolonged acidosis is a feature of SGLT2i-induced euglycaemic diabetic ketoacidosis.

SummaryWe describe two cases of SGLT2i-induced euglycaemic diabetic ketoacidosis, which took longer than we anticipated to treat despite initiation of our DKA protocol. Both patients had an unequivocal diagnosis of type 2 diabetes, had poor glycaemic control with a history of metformin intolerance and presented with relatively vague symptoms post-operatively. Neither patient had stopped their SGLT2i pre-operatively, but ought to have by current treatment guidelines.Learning points:SGLT2i-induced EDKA is a more protracted and prolonged metabolic derangement and takes approximately twice as long to treat as hyperglycaemic ketoacidosis.Surgical patients ought to stop SGLT2i medications routinely pre-operatively and only resume them after they have made a full recovery from the operation.While the mechanistic basis for EDKA remains unclear, our observation of marked ketonuria in both patients suggests that impaired ketone excretion may not be the predominant metabolic lesion in every case.Measurement of insulin, C-Peptide, blood and urine ketones as well as glucagon and renal function at the time of initial presentation with EDKA may help to establish why this problem occurs in specific patients.

Transcriptome analysis of rumen epithelium and meta-transcriptome analysis of rumen epimural microbial community in young calves with feed induced acidosis

Many common management practices used to raise dairy calves while on milk and during weaning can cause rumen acidosis. Ruminal pH has long been used to identify ruminal acidosis. However, few attempts were undertaken to understand the role of prolonged ruminal acidosis on rumen microbial community or host health in young calves long after weaning. Thus, the molecular changes associated with prolonged rumen acidosis in post weaning young calves are largely unknown. In this study, we induced ruminal acidosis by feeding a highly processed, starch-rich diet to calves starting from one week of age through 16 weeks. Rumen epithelial tissues were collected at necropsy at 17 weeks of age. Transcriptome analyses on the rumen epithelium and meta-transcriptome analysis of rumen epimural microbial communities were carried out. Calves with induced ruminal acidosis showed significantly less weight gain over the course of the experiment, in addition to substantially lower ruminal pH in comparison to the control group. For rumen epithelial transcriptome, a total of 672 genes (fold-change, FC ≥ 1.5; adjusted-p ≤ 0.05) showed significant differential expression in comparison to control. Biological pathways impacted by these differentially expressed genes included cell signaling and morphogenesis, indicating the impact of ruminal acidosis on rumen epithelium development. rRNA read-based microbial classification indicated significant increase in abundance of several genera in calves with induced acidosis. Our study provides insight into host rumen transcriptome changes associated with prolonged acidosis in post weaning calves. Shifts in microbial species abundance are promising for microbial species-based biomarker development and artificial manipulation. Such knowledge provides a foundation for future more precise diagnosis and preventative management of rumen acidosis in dairy calves.

Persistent Lactic Acidosis during Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy Predicts Adverse Outcome

Background: Prolonged lactic acidosis (LA) correlates with severe cerebral injury in asphyxiated animal models. Few studies have evaluated LA and lactate clearance in neonates undergoing therapeutic hypothermia (TH) for hypoxicischemic encephalopathy (HIE). We hypothesize that delayed normalization of serum lactate during TH reflects a more severe cerebral injury. Objective: To determine whether degree of LA prior to initiation of TH, as well as serum lactate clearance and time to normalization of serum lactate level during TH, can …

Atypical Diabetic Ketoacidosis in a Young Female

Diabetic ketoacidosis is a life threatning complication of Diabetes Milletus and can be catastrophic if left untreated.Being one of the most common complications but sometime with no clear history and symptoms the diagnosis become difficult. Hence emergency physicians should keep a broad vision while dealing with young patients with high glucose level. Diabetic ketoacidosis may be the first symptom of previously undiagnosed Diabetes. It is diagnosed with combination of Hyperglycemia, Acidosis and Ketonuria. Patients with prolonged acidosis and tendency to hypokalemia should be investigated for consumption of synthetic cannabinoids. No literature till date have showen Metabolic acidosis with PCO2 4.7 mmHg and HCO 3 1.3 mmol/L.

Predictors and Outcome of Acute Kidney Injury in Children with Diabetic Ketoacidosis

To identify predictors and outcome of acute kidney injury (AKI) in children with diabetic ketoacidosis (DKA) admitted to a Pediatric Intensive Care Unit (PICU). Retrospective case review of 79 children with DKA admitted between 2011-2014. Twenty eight children developed AKI during the hospital stay; 20 (71.4%) recovered with hydration alone. Serum chloride at 24 hours was independently associated with AKI. Children with AKI had prolonged acidosis and PICU stay and higher mortality. Majority of children with AKI and DKA, recover with hydration. Hyperchloremia at 24 hours had independent association with AKI, although cause-effect relation could not be ascertained.

The factors affecting resolution of acidosis in children with diabetic ketoacidosis - A retrospective study from a tertiary care center in India

Background: Diabetic ketoacidosis (DKA) is characterized by a spectrum of clinical manifestations due to deficiency of insulin which results in hyperglycemia, ketonemia with ketonuria, and metabolic acidosis. Administration of insulin inhibits the production of keto acids and facilitates their metabolism, thereby helps in correcting the acidosis. However, in some situations, the acidosis takes longer to get corrected. Objectives: The aim of this study is to evaluate the factors at admission predicting the duration of acidosis in a child presenting with DKA. Methods: Study Type: This was a retrospective case record review. Inclusion Criterion: All children &lt;15 years who were admitted under the pediatric intensive care unit of a tertiary care hospital from April 2012 to January 2016 with DKA were included in this study. Their demographic data, investigations, treatment details, and length of hospital stay were noted in a predesigned pro forma. Prolonged acidosis was defined as acidosis taking longer than 24 h to resolve. Results: Forty-eight cases met the inclusion criteria; of the 48 cases, 27 (56%) had prolonged acidosis. The median duration of correction of acidosis was 31 h (interquartile range 18.75-48 h/range of 6-192 h). On univariate analysis, children with prolonged acidosis had a low pH (7.1 vs. 7.25), a low serum bicarbonate (4.69 vs. 7.49 mEq/L), base excess (?22.7 vs ?17.04), a high total leukocyte count (TLC) (24,275 vs. 13,557 cells/mm3), and platelet count (450,651 vs. 316,140 cells/mm3) at admission (t-test, p&lt;0.05). On stepwise logistic regression analysis, only low pH and a high TLC were associated with prolonged acidosis.The presence of rhabdomyolysis and myocardial impairment and degree of dehydration at admission which could contribute to prolonged acidosis were not measured in this study. Conclusion: Prolonged acidosis (lasting more than 24 h) was associated with a high TLC and a low pH at admission.

Hypoxia-induced cardiac injury in dystrophic mice.

Duchenne muscular dystrophy (DMD) is a disease of progressive destruction of striated muscle, resulting in muscle weakness with progressive respiratory and cardiac failure. Respiratory and cardiac disease are the leading causes of death in DMD patients. Previous studies have suggested an important link between cardiac dysfunction and hypoxia in the dystrophic heart; these studies aim to understand the mechanism underlying this connection. Here we demonstrate that anesthetized dystrophic mice display significant mortality following acute exposure to hypoxia. This increased mortality is associated with a significant metabolic acidosis, despite having significantly higher levels of arterial Po2 Chronic hypoxia does not result in mortality, but rather is characterized by marked cardiac fibrosis. Studies in isolated hearts reveal that the contractile function of dystrophic hearts is highly susceptible to short bouts of ischemia, but these hearts tolerate prolonged acidosis better than wild-type hearts, indicating an increased sensitivity of the dystrophic heart to hypoxia. Dystrophic hearts display decreased cardiac efficiency and oxygen extraction. Isolated dystrophic cardiomyocytes and hearts have normal levels of FCCP-induced oxygen consumption, and mitochondrial morphology and content are normal in the dystrophic heart. These studies demonstrate reductions in cardiac efficiency and oxygen extraction of the dystrophic heart. The underlying cause of this reduced oxygen extraction is not clear; however, the current studies suggest that large disruptions of mitochondrial respiratory function or coronary flow regulation are not responsible. This finding is significant, as hypoxia is a common and largely preventable component of DMD that may contribute to the progression of the cardiac disease in DMD patients.

Ischemic postconditioning in cerebral ischemia: Differences between the immature and mature brain?

Ischemic postconditioning (postC), defined as serial mechanical interruptions of blood flow at reperfusion, effectively reduces myocardial infarct size in all species tested so far, including humans. In the brain, ischemic postC leads to controversial results regardless of variations in factors such as onset time of beginning, the duration of ischemia and/or reperfusion, and the number of cycles of occlusion/reperfusion. Thus, many major issues remain to be resolved regarding its protective effects. Future studies should aim to identify the parameters that yield the strongest protection, as well as to understand why the efficacy of ischemic postC differs between models. This review will focus on initial hemodynamic changes and their consequences, and on specific features such as NO-dependent vascular tone and/or prolonged acidosis in cerebral ischemia-reperfusion in order to better understand the dynamics of ischemic postC in the developing brain.

Atypical diabetic ketoacidosis: case report.

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus and can lead to death if untreated. It is a complex metabolic state characterised by hyperglycaemia, acidosis and ketonuria. Bonsai is one of the herbal incense products that contains synthetic cannabinoid and can be easily accessible via the internet in many countries. It cannot be detected in blood and urine studies using conventional methods. Synthetic cannabinoid abuse is associated with severe side effects, including tachycardia, high blood pressure, acidosis, excess sedation and coma. A 17-year-old male patient was brought to the emergency department with sudden onset of dyspnoea. Laboratory investigations revealed hyperglycaemia, acidosis and ketonuria. He was admitted to the intensive care unit with a diagnosis of diabetic ketoacidosis. He was not considered a typical case of diabetic ketoacidosis because of the tendency to hypokalaemia, persistent tachycardia and bronchoscopic findings. We learned from his friends that he had used cannabis for a week and used bonzai on the day that he was brought to the emergency service. Diabetic ketoacidosis with prolonged acidosis and tendency to hypokalaemia are investigated for the consumption of synthetic cannabinoids.

PO-0056 Clinical And Laboratory Findings Of Diabetic Ketoacidosis In A Picu Of Albania

Introduction Delay diagnosis is the major cause of Diabetic ketoacidosis (DKA). Children with profound acidosis are at great risk for symptomatic cerebral oedema. Objective To identify the epidemiological profile, clinical feature, factors related to delayed diagnosis in children with DKA and to analyse the factors associated with prolonged acidosis. Methods We analysed the records of all children with DKA, admitted to our PICU during January 2004–December 2013. We evaluated clinical features, biochemical profile at admission, 6, 12 and 24 hrs, presence of sepsis, shock, complications and outcome. The severity of DKA was defined by the degree of acidosis: mild (pH = 7.2–7.3), moderate (7.1–7.2) and severe (pH Results Mean age of the patients was 7.06 ± 4.24 years, with misdiagnosis in 32% of cases. By the degree of acidosis, DKA was mild in 16%, moderate in 56% and severe in 28% of cases, with prolonged acidosis (>24 hrs) in 36% of cases. Factors associated with prolonged acidosis were: Na >133 mEq/L (p = 0.01), HCO 3 - >100 mEq/L (p = 0.02) and AG >25.1 (p = 0.03). HbA 1 C, azotemia, DG and misdiagnosis didn’t resulted significative for prolonged acidosis. Three cases are complicated with cerebral oedema. Initial blood glucose or decline in glucose had no association with cerebral oedema. Mortality rate was 8%. Conclusion Misdiagnosis of diabetes with DKA as consequence, is still high in children in Albania. Clinical and laboratory findings help identifying the patients who require a higher level of intervention.