Severity Of Metabolic Acidosis Research Articles

Sulfuric Acid Ingestion: May the Severity of the Metabolic Acidosis be Considered as a Predictive Sign of Late Damage to the Gastrointestinal Tract?

Caustic substances ingestion results in a complex syndrome. The patient characteristics and severity of injury are important prognostic predictors. The monitoring of clinical changes and the multidisciplinary approach are necessary to prevent death in the early stages of the poisoning. The case report describes the suicide of a woman by ingestion of a large amount of 15% sulfuric acid for suicidal purposes (15-20 ml). The initial conditions were stable, and no changes were found on a CT scan. However, the main sign was a severe metabolic acidosis. After 7 hours, haematemesis and oedema of the larynx appeared, and oro-tracheal intubation and ICU admission were necessary. Consequent progressive haemodynamic deterioration with persistent severe metabolic acidosis, increasing lactates and septic shock appeared. A new CT scan with contrast was performed 22 hours later detecting diffuse perforations and liquid in pleurae and abdomen. A pleural sample showed necrotic liquid. The death was 24 hours after ingestion and no surgical treatment was performed because of the diffuse lesions to the thoracoabdominal districts. Early detection of gastroenteric lesions and the monitoring of clinical changes are mandatory to avoid the death of the patient. Gastroenteric perforations require an immediate radiological evaluation and surgical treatment. The clinical case report states the severity of prognosis was related to high doses of sulfuric acid ingestion. The immediate metabolic acidosis is related to quick subsequent severe systemic pathological lesions of the gastrointestinal tract. The severity of absorption metabolic acidosis, consequently, may be an early and prognostic sign of the late chest and abdominal lesions. Severity of metabolic acidosis after sulfuric acid ingestion may anticipate late damage to the gastrointestinal tract.

ВЗАИМОСВЯЗЬ КИСЛОТНО-ОСНОВНОГО СОСТОЯНИЯ И АЗОТЕМИИ У ПАЦИЕНТОВ С ОСТРЫМ ПОЧЕЧНЫМ ПОВРЕЖДЕНИЕМ И ХРОНИЧЕСКОЙ БОЛЕЗНЬЮ ПОЧЕК

There are some differences in analyses in patients with end-stage chronic kidney disease and acute renal injury at the early stages of differential diagnosis. A correlation analysis was carried out, a relationship was found between the severity of metabolic acidosis and creatinine level in patients with chronic kidney disease, while no such association was found in acute renal injury.

Association of metabolic acidosis with fractures, falls, protein-calorie malnutrition and failure to thrive in patients with chronic kidney disease.

ABSTRACTBackgroundThe risk of adverse geriatric outcomes such as falls and fractures is high among patients with chronic kidney disease (CKD). Metabolic acidosis is associated with protein catabolism and bone loss in experimental animal and human studies. We sought to quantify the independent association of metabolic acidosis with adverse muscle, bone and functional outcomes in a large US community-based cohort.MethodsThe Optum's de-identified Integrated Claims-Clinical dataset of US patients (2007–2017) was used to generate a cohort of patients with nondialysis-dependent CKD who had estimated glomerular filtration rate >10 to <60 mL/min/1.73 m2 and two serum bicarbonate values 12 to <22 mmol/L or 22–29 mmol/L. The primary outcomes were failure to thrive, protein-calorie malnutrition, and fall or fracture. Cox proportional hazards models were used for the primary outcomes for up to 10 years, while logistic regression models were used at 2 years.ResultsA total of 51 558 patients qualified for the study, with a median [Interquartile Range (IQR)] follow-up time of 4.2 (2.5–5.8) years. Over a ≤10-year period, for each 1 mmol/L increase in serum bicarbonate, the hazard ratios (adjusted for age, sex, race, estimated glomerular filtration rate, serum albumin, hemoglobin, diabetes and cardiovascular comorbidities) for failure to thrive, protein-calorie malnutrition and fall or fracture were 0.91 [95% confidence interval (CI): 0.90–0.92], 0.91 (95% CI: 0.90–0.92) and 0.95 (95% CI: 0.95–0.96), all P < 0.001, respectively.ConclusionsThe presence and severity of metabolic acidosis was a significant, independent risk factor for failure to thrive, protein-calorie malnutrition and fall or fracture in this large community cohort of patients with stage 3–5 CKD.

Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study

BackgroundMetabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood.MethodThis was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < –4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model.ResultsWe screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality.ConclusionsEarly metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Methanol poisoning in Turkey: Two outbreaks, a single center experience.

Methanol poisoning is still one of the major causes of mortality due to intoxication because of the challenging diagnosis and late hospital admissions. We aimed to evaluate epidemiological data, clinical characteristics, laboratory findings, treatment protocols, and prognosis of patients in a tertiary hospital in two different methanol outbreaks occurring in a three-year interval. The study was planned as a single-center and retrospective observational case series study. Patients ≥18 years of age who were admitted to the hospital between 1 September 2016 and 1 September 2019 and diagnosed with methanol poisoning were included in the study. Sixty-seven patients whose data were sufficient and accessible were included in the study. Thirty-five (52.2%) patients were discharged without sequelae, 14 (20.9%) patients were discharged with sequelae (both central nervous system sequelae and visual sequelae in 3 patients, only visual sequelae in 11 patients) and 18 (26.9%) patients died. High anion gap (AG) metabolic acidosis (pH<7.07, AG>26.7), low Glasgow Coma Score, and increased lactate (lactate>2.55mmol/L) levels were found to be associated with poor outcome. Folate use in treatment did not have a statistically significant effect (p=0.087) on the prevention of visual sequelae development, but it had a statistically significant effect on mortality (p=0.041). State of consciousness and the severity of metabolic acidosis were significant parameters associated with mortality. In addition to antidote and elimination therapies, given the benefit on mortality and low risk of adverse events, folate therapy should be considered for all patients with significant toxic methanol exposures.

Reactive carbonyl compounds, carbonyl stress, and neuroinflammation in methyl alcohol intoxication

Methyl alcohol intoxications are characterized by high lethality and high prevalence of serious visual and brain damage in survivors. The mechanisms of toxic brain damage are complex and the role of carbonyl stress has not been studied yet. We measured the acute and follow-up concentrations of reactive carbonyl compounds in patients with acute methyl alcohol intoxication. Blood samples were collected from 28 subjects hospitalized with confirmed methyl alcohol intoxication and from 36 subjects who survived poisoning 2 years after discharge. Serum concentrations of C6–12 reactive aldehydes were measured by liquid chromatography–electrospray ionization–tandem mass spectrometry. The acute concentrations of all measured reactive aldehydes were higher than the follow-up concentrations: 36.4 ± 4.8 vs. 21.6 ± 5.2 ng cm−3 for C6; 38.9 ± 5 vs. 17.0 ± 2.0 ng cm−3 for C7; 18.8 ± 3.9 vs. 4 ± 0 cm−3 for C8; 36.5 ± 3.9 vs. 19.0 ± 3.0 ng cm−3 for C9; 6.1 ± 0.4 vs. 4.0 ± 0.5 ng cm−3 for C10; 13.6 ± 3.0 vs. 3.7 ± 0.6 ng cm−3 for C11; and 7.8 ± 0.4 vs. 4.7 ± 0.4 ng cm−3 for C12 (all p < 0.001). The patients who survived the intoxication had higher concentration of reactive carbonyl compounds than those who died: 38.6 ± 5.9 vs. 28.3 ± 1.7 ng cm−3 for C6 (p = 0.002); 20.7 ± 4.7 vs. 11.8 ± 1.2 ng cm−3 for C8 (p = 0.001); 37.7 ± 4.8 vs. 31.8 ± 3.8 ng cm−3 for C9 (p = 0.042); and 7.9 ± 0.6 vs. 7.3 ± 0.5 ng cm−3 for C12 (p = 0.022). A significant association was present between severity of metabolic acidosis, anion gap, and the acute concentration of measured biomarkers: r = − 0.39; p = 0.046 for C6; r = − 0.42; p = 0.035 for C7; r = − 0.48; p = 0.012 for C8; r = − 0.39; p = 0.046 for C9; and r = − 0.47; p = 0.015 for C11. The acute concentration of C6–C12 reactive aldehydes positively correlated with the acute serum concentration of leukotrienes (all p < 0.05). Acute elevation of serum concentration of reactive carbonyl compounds suggests that carbonyl stress is involved in the mechanisms of leukotriene-mediated neuroinflammatory response to methyl alcohol-induced toxic brain damage.

Prediction and validation of the duration of hemodialysis sessions for the treatment of acute ethylene glycol poisoning

The duration of hemodialysis (HD) sessions for the treatment of acute ethylene glycol poisoning is dependent on concentration, the operational parameters used during HD, and the presence and severity of metabolic acidosis. Ethylene glycol assays are not readily available, potentially leading to undue extension or premature termination of HD. We report a prediction model for the duration of high-efficiency HD sessions based retrospectively on a cohort study of 26 cases of acute ethylene glycol poisoning in 24 individuals treated by alcohol dehydrogenase competitive inhibitors, cofactors and HD. Two patients required HD formore than 14 days, and two died. In 19 cases, the meanethylene glycol elimination half-life during high-efficiency HD was 165 minutes (95% confidence interval of151-180 minutes). In a training set of 12 patients with acute ethylene glycol poisoning, using the 90th percentile half-life (195 minutes) and a target ethylene glycol concentration of 2 mmol/l (12.4 mg/dl) allowed all cases to reach a safe ethylene glycol under 3 mmol/l (18.6 mg/dl). The prediction model was then validated in a set of seven acute ethylene glycol poisonings. Thus, the HD session time in hours can be estimated using 4.7 x (Ln [the initial ethylene glycol concentration (mmol/l)/2]), provided that metabolic acidosis is corrected.

The frequency and severity of metabolic acidosis related to topiramate.

ObjectiveWe planned a cross-sectional analysis to determine the frequency and severity of metabolic acidosis in patients taking topiramate while awaiting craniotomy.MethodsEighty patients (18 – 65 years) taking topiramate to control seizures while awaiting elective craniotomy were enrolled. Any signs of metabolic acidosis or topiramate-related side effects were investigated. Blood chemistry levels and arterial blood gases, including lactate, were obtained. The severity of metabolic acidosis was defined according to base excess levels as mild or moderate.ResultsBlood gas analysis showed that 71% (n = 57) of patients had metabolic acidosis. The frequency of moderate metabolic acidosis was 56% (n = 45), while that of mild metabolic acidosis was 15% (n = 12). A high respiratory rate was reported in only 10% of moderately acidotic patients.ConclusionsIn patients receiving topiramate, baseline blood gas analysis should be performed preoperatively to determine the presence and severity of metabolic acidosis.

Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia.

Diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and hypoglycaemia are serious complications of diabetes mellitus that require prompt recognition, diagnosis and treatment. DKA and HHS are characterized by insulinopaenia and severe hyperglycaemia; clinically, these two conditions differ only by the degree of dehydration and the severity of metabolic acidosis. The overall mortality recorded among children and adults with DKA is <1%. Mortality among patients with HHS is ~10-fold higher than that associated with DKA. The prognosis and outcome of patients with DKA or HHS are determined by the severity of dehydration, the presence of comorbidities and age >60 years. The estimated annual cost of hospital treatment for patients experiencing hyperglycaemic crises in the USA exceeds US$2 billion. Hypoglycaemia is a frequent and serious adverse effect of antidiabetic therapy that is associated with both immediate and delayed adverse clinical outcomes, as well as increased economic costs. Inpatients who develop hypoglycaemia are likely to experience a long duration of hospital stay and increased mortality. This Review describes the clinical presentation, precipitating causes, diagnosis and acute management of these diabetic emergencies, including a discussion of practical strategies for their prevention.

Sodium bicarbonate use and the risk of hypernatremia in thoracic aortic surgical patients with metabolic acidosis following deep hypothermic circulatory arrest.

Objective:Metabolic acidosis after deep hypothermic circulatory arrest (DHCA) for thoracic aortic operations is commonly managed with sodium bicarbonate (NaHCO3). The purpose of this study was to determine the relationships between total NaHCO3 dose and the severity of metabolic acidosis, duration of mechanical ventilation, duration of vasoactive infusions, and Intensive Care Unit (ICU) or hospital length of stay (LOS).Methods:In a single center, retrospective study, 87 consecutive elective thoracic aortic operations utilizing DHCA, were studied. Linear regression analysis was used to test for the relationships between the total NaHCO3 dose administered through postoperative day 2, clinical variables, arterial blood gas values, and short-term clinical outcomes.Results:Seventy-five patients (86%) received NaHCO3. Total NaHCO3 dose averaged 136 ± 112 mEq (range: 0.0–535 mEq) per patient. Total NaHCO3 dose correlated with minimum pH (r = 0.41, P < 0.0001), minimum serum bicarbonate (r = −0.40, P < 0.001), maximum serum lactate (r = 0.46, P = 0.007), duration of metabolic acidosis (r = 0.33, P = 0.002), and maximum serum sodium concentrations (r = 0.29, P = 0.007). Postoperative hypernatremia was present in 67% of patients and peaked at 12 h following DHCA. Eight percent of patients had a serum sodium ≥ 150 mEq/L. Total NaHCO3 dose did not correlate with anion gap, serum chloride, not the duration of mechanical ventilator support, vasoactive infusions, ICU or hospital LOS.Conclusion:Routine administration of NaHCO3 was common for the management of metabolic acidosis after DHCA. Total dose of NaHCO3 was a function of the severity and duration of metabolic acidosis. NaHCO3 administration contributed to postoperative hypernatremia that was often severe. The total NaHCO3 dose administered was unrelated to short-term clinical outcomes.

Prevalence and severity of metabolic acidosis in patients on maintenance hemodialysis in India

Aim: Metabolic acidosis is a feature of chronic kidney disease (CKD) due to the reduced capacity of the kidney to synthesize ammonia and excrete hydrogen ions. Among the many goals of hemodialysis (HD), the role in correction of metabolic acidosis is an important one. To assess the prevalence and severity of metabolic acidosis in the Indian patients of CKD, who are on maintenance HD (MHD). Methods: This is a cross-sectional study on 35 patients conducted at two centers in Western part of India. The demographic, clinical, and laboratory assessments were done on chronic stable patients receiving MHD. The prevalence and severity of metabolic acidosis were evaluated. Results: Metabolic acidosis was found in 22 out of 35 patients (62.85%), with mean predialysis serum pH and HCO 3 of 7.32 ± 0.083 and 20.37 ± 4.94 mmol/L, respectively. Conclusion: Metabolic acidosis is significantly prevalent in patients on MHD in India.

Prevalence and severity of metabolic acidosis in patients on maintenance hemodialysis in India

Prevalence and severity of metabolic acidosis in patients on maintenance hemodialysis in India

Inclusion of Molasses or Glucose Syrup in Starter Concentrate for Dairy Calves: Effects on Diarrheic Calves

Severity of metabolic acidosis and other clinical signs in diarrheic dairy calves fed a starter concentrate containing molasses or glucose syrup as a replacement for corn were evaluated. Thirty-two calves were blocked according to birth weight and were divided into four treatments according to starter concentrate composition: (1) Control, starter concentrate based on corn; (2) 5% of molasses as a replacement for corn; (3) 10% of molasses as a replacement for corn; (4) 5% glucose syrup as a replacement for corn. Animals were individually housed with free access to water and concentrate and received 4 L/d of milk replacer. Blood samples were analyzed and evaluations of fecal score, clinical score and physiological parameters were performed during the first three days of all diarrhea event. Starter concentrate composition did not negatively affect (p>0.05) fecal scores or diarrhea clinical signals. Blood gas, electrolytic and biochemical analyses do not indicated hydration, acidosis, or other metabolic disorders (p>0.05). However, higher level of molasses increased hematocrit (p<0.04), suggesting higher dehydration condition. Inclusion of these by products as a replacement for corn in the concentrate did not alter the animals' metabolism in response to the occurrence of diarrhea and can therefore be utilized in the feed without causing damage to the animal’s health.

Prediction and validation of hemodialysis duration in acute methanol poisoning

The duration of hemodialysis (HD) in methanol poisoning (MP) is dependent on the methanol concentration, the operational parameters used during HD, and the presence and severity of metabolic acidosis. However, methanol assays are not easily available, potentially leading to undue extension or premature termination of treatment. Here we provide a prediction model for the duration of high-efficiency HD in MP. In a retrospective cohort study, we identified 71 episodes of MP in 55 individuals who were treated with alcohol dehydrogenase inhibition and HD. Four patients had residual visual abnormality at discharge and only one patient died. In 46 unique episodes of MP with high-efficiency HD the mean methanol elimination half-life (T1/2) during HD was 108 min in women, significantly different from the 129 min in men. In a training set of 28 patients with MP, using the 90th percentile of gender-specific elimination T1/2 (147 min in men and 141 min in women) and a target methanol concentration of 4 mmol/l allowed all cases to reach a safe methanol of under 6 mmol/l. The prediction model was confirmed in a validation set of 18 patients with MP. High-efficiency HD time in hours can be estimated using 3.390 × (Ln (MCi/4)) for women and 3.534 × (Ln (MCi/4)) for men, where MCi is the initial methanol concentration in mmol/l, provided that metabolic acidosis is corrected.

Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation.

BackgroundOur group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time.MethodsThree hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥−5.5 mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort.ResultsAll 335 patients achieved the desired level of resuscitation within 36 h of injury. Two hundred sixty-nine (80 %) were treated within 36 h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71 %. Complications occurred in 16.3 % of patients fixed within 36 h and in 33.3 % of delayed patients (p = 0.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3 days and 4.4 versus 11.6 days, respectively, both p < 0.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1 %, p = 0.017) and shorter length of stay (LOS) (p = 0.018).ConclusionsOur EAC protocol recommends definitive fixation within 36 h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.

Severity and Duration of Metabolic Acidosis After Deep Hypothermic Circulatory Arrest for Thoracic Aortic Surgery.

To determine the severity, duration, and contributing factors for metabolic acidosis after deep hypothermic circulatory arrest (DHCA). Retrospective observational study. University hospital. Eighty-seven consecutive patients undergoing elective thoracic aortic surgery with DHCA. Regression analysis was used to test for relationships between the severity of metabolic acidosis and clinical and laboratory variables. Minimum pH averaged 7.27±0.06, with 76 (87%) having a pH<7.35; 55 (63%), a pH<7.30; and 7 (8%), a pH<7.20. The mean duration of metabolic acidosis was 7.9±5.0 hours (range: 0.0 - 26.8), and time to minimum pH after DHCA was 4.3±2.0 hours (1.0 - 10.0 hours). Hyperchloremia contributed to metabolic acidosis in 89% of patients. The severity of metabolic acidosis correlated with maximum lactate (p<0.0001) and hospital length of stay (LOS) (r = 0.22, p<0.05), but not with DHCA time, DHCA temperature, duration of vasoactive infusions, or ICU LOS. Patient BMI was the sole preoperative predictor of the severity of postoperative metabolic acidosis. This retrospective analysis involved short-term clinical outcomes related to pH severity and duration, which indirectly may have included the impact of sodium bicarbonate administration. Metabolic acidosis was common and severe after DHCA and was attributed to both lactic and hyperchloremic acidosis. DHCA duration and temperature had little impact on the severity of metabolic acidosis. The severity of metabolic acidosis was best predicted by the BMI and had minimal effects on short-term outcomes. Preventing hyperchloremic acidosis has the potential to decrease the severity of metabolic acidosis after DHCA.

Czech mass methanol outbreak 2012: Epidemiology, challenges and clinical features

Objectives. Methanol poisonings occur frequently globally, but reports of larger outbreaks where complete clinical and laboratory data are reported remain scarce. The objective of the present study was to report the data from the mass methanol poisoning in the Czech Republic in 2012 addressing the general epidemiology, treatment, and outcomes, and to present a protocol for the use of fomepizole ensuring that the antidote was provided to the most severely poisoned patients in the critical phase. Methods. A combined prospective and retrospective case series study of 121 patients with confirmed methanol poisoning. Results. From a total of 121 intoxicated subjects, 20 died outside the hospital and 101 were hospitalized. Among them, 60 survived without, and 20 with visual/CNS sequelae, whereas 21 patients died. The total and hospital mortality rates were 34% and 21%, respectively. Multivariate regression analysis found pH < 7.0 (OR 0.04 (0.01–0.16), p < 0.001), negative serum ethanol (OR 0.08 (0.02–0.37), p < 0.001), and coma on admission (OR 29.4 (10.2–84.6), p < 0.001) to be the only independent parameters predicting death. Continuous hemodialysis was used more often than intermittent hemodialysis, but there was no significant difference in mortality rate between the two [29% (n = 45) vs 17% (n = 30), p = 0.23]. Due to limited stockpiles of fomepizole, ethanol was administered more often; no difference in mortality rate was found between the two [16% (n = 70) vs. 24% (n = 21), p = 0.39]. The effect of folate administration both on the mortality rate and on the probability of visual sequelae was not significant (both p > 0.05). Conclusions. Severity of metabolic acidosis, state of consciousness, and serum ethanol on admission were the only significant parameters associated with mortality. The type of dialysis or antidote did not appear to affect mortality. Recommendations that were issued for hospital triage of fomepizole administration allowed conservation of valuable antidote in this massive poisoning outbreak for those patients most in need.

D-Lactate: A Novel Contributor to Metabolic Acidosis and High Anion Gap in Diabetic Ketoacidosis

To the Editor: Diabetic ketoacidosis (DKA),the most common and serious acute complication of diabetes, is characterized by hyperglycemia and severe high–anion-gap metabolic acidosis with ketonemia (1). In DKA, the high anion gap is attributed largely to excessive production of blood ketone bodies, and serum β-hydroxybutyrate quantification is recommended for the diagnosis and monitoring of DKA (2). However, even counting of all the ketone bodies, including β-hydroxybutyrate, does not account for the entire anion gap, suggesting that there are additional sources of anion production in DKA. We recently demonstrated that plasma d-lactate concentrations were greatly increased in DKA compared with the concentrations in diabetic patients or a healthy control group (3). Nevertheless, the clinical value of d-lactate measurement in metabolic acidosis, especially the contribution of d-lactate to the metabolic acidosis and high anion gap in DKA, is not well appreciated. We report here that decreasing d-lactate concentrations are associated with improved clinical situations, whereas increased lactate concentrations are associated with the severity of metabolic acidosis and high anion gap …

The Role of Renal Regulatory Mechanisms in the Evolution and Treatment of Pediatric Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a life threatening complication of diabetes mellitus in pediatric patients with new onset insulin dependent diabetes. Despite advances in therapy mortality from DKA, especially in children less than two years, remains high. This review highlights the role of obligatory renal defense mechanisms in the evolution of DKA and its implication for therapy: to accomplish this goal the review starts with a cursory description of the pathogenesis and pathophysiology of metabolic derangements in DKA as a basis for understanding the renal compensatory mechanisms geared towards restoration of acid-base balance; then, the next section of the review describes how alterations in fluid and electrolyte balance at the onset of DKA and the extent of renal regulatory defense mechanisms geared towards its restoration can predispose to cerebral edema at the beginning of therapy. We conclude by suggesting that restoration of fluid and electrolyte balance should be based on the severity of metabolic acidosis as determined by the extent of renal impairment at the onset and during the course of DKA rather than strictly by protocols.

Does the Model for End-Stage Liver Disease Score Predict Transfusion Amount, Acid-Base Imbalance, Haemodynamic and Oxidative Abnormalities during Living Donor Liver Transplantation?

The model for end-stage liver disease (MELD) score is associated with the severity of liver failure in transplant patients. This study examined whether life-threatening stress factors during liver transplantation differed according to the patients' preoperative MELD scores. Forty-four patients who underwent living donor liver transplantation were divided into a high MELD group (MELD score ≥ 20) (n = 25) and a low MELD group (MELD score < 20) (n = 19). The volume of blood components transfused, acid-base homeostasis variables, and haemodynamic and oxidative variables were measured at each stage of the surgery. The systemic vascular resistance index was significantly lower in the high MELD group than in the low MELD group at all time points. The oxygen utility index and the oxygen extraction ratio were all significantly lower in the high MELD group than in the low MELD group only at the preanhepatic stage and not at later stages of surgery. Intraoperative transfusion volume and the severity of metabolic acidosis were not associated with the preoperative MELD score.