Management of diabetic ketoacidosis

Dr Louise Johnson informs on what diabetic ketoacidosis is, the signs and how to manage it.

What is diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is an acute life-threatening complication of diabetes. DKA happens when your blood glucose is very high and acidic substances, called ketones, build up to dangerous levels in your body. It’s characterised by high glucose and ketonuria (ketones on dipstick in urine) and ketoacidosis.

The cause is due to decreased amount of insulin and too much glucose. The metabolism shifts from the carbohydrate metabolism to a starvation state where the fat metabolism is used.

 Signs and symptoms

  • General weakness, tiredness
  • Polyuria (passing a large amount of urine) and polydipsia (excessive thirst)
  • Nausea and vomiting
  • Abdominal pain
  • Decreased appetite
  • Rapid weight loss in a new Type 1 diabetes patient
  • Altered consciousness, disorientation and confusion
  • Decreased sweating with dry skin
  • Dehydration
  • Laboured breathing, called Kussmaul breathing
  • Apple smell on the breath
  • Dizziness due to low blood pressure and palpitations
  • Glucose more than 20 mmol/L and ketones on some glucose machines (if possible) and in urine as detected by a urine dipstick

Causes of DKA

  • Infection, especially bladder infections, lung infection, feet, tooth or other
  • Inflammation i.e. arthritis
  • Heart attack characterised by chest pain
  • Not taking insulin or enough insulin
  • Insulin not delivered due to pump obstruction or insulin pump failure
  • Trauma that can be either physical or emotional. The death of a pet is enough emotional stress to cause this.

The incidence of DKA is mainly in Type 1 diabetes but can also be seen in Type 2 diabetes that are on insulin and develop a bad infection.

In Type 1 diabetes it’s more common in young children and adolescents due to growth hormone and sex hormones that increases. It’s also seen in adolescents with psychological stress where insulin is not taken correctly or omitted on purpose.

Management of DKA

The most important factor is to test blood glucose when any of the signs are present. Nausea and abdominal pain are early signs that can be used to prevent hospitalisation.

If you are showing any signs, you should check your blood glucose and give a short-acting insulin as a correction to bring the glucose down below 10 mmol/L.

Drink clear water in an amount of 100ml/kg. In a person weighing 60kg that would be six litres. Drink the water slowly and check glucose every hour. About 1 litre fluid per hour.

Should there be excessive nausea, an anti-emiticum can be used for nausea, such as Valoid suppository.

If there are no signs of infection and the glucose is responding to the treatment, you can stay at home. In the case where the glucose is not responding and vomiting or confusion appears, you will need to be admitted to a hospital for intravenous insulin.

Prognosis

The overall mortality rate for DKA is 0,2 to 2% with persons with coma having the worse prognosis.

In properly treated patients, the prognosis is excellent. Before the discovery of insulin, in 1922, the mortality was 100%. Over the last three decades, the mortality rates from DKA have markedly decreased from 7,96% to 0,67%1.

Dr Louise Loot

MEET THE EXPERT


Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.



References:

  1. Lin SF, LIN JD et. al. “ Diabetic ketoacidosis: comparison of patient characteristics, clinical presentations and outcomes today and 20 years ago.” Chaung Gung Med J 2005, Jan 28(1):24-30

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Oral health related to diabetes

Oral hygienist, Sarie Liebenberg, educates us on oral health related to diabetes and whether you should go to a dentist during COVID-19.


There is a direct link between oral health and systemic conditions, like diabetes, respiratory disease and cardiovascular disease. Therefore, it’s of utmost importance to exercise good oral health in the presence of one or more of these underlying systemic diseases.

Should I go to the dentist during COVID-19?

Currently, with the COVID-19 pandemic, you might wonder if it’s important and necessary to go to the dentist/hygienist. The answer is a definite ‘yes’.

HIV-AIDS, tuberculosis and hepatitis, to only mention a few, have been around for a very long time. COVID-19 is just another addition to the list.

Dental professionals are trained to prevent the transfer of bacteria and viruses. Not only does the dental professional have adequate protective measures to prevent the transfer of bacteria and/or viruses from one person to another, but also have the knowledge and understanding not to cross contaminate their working environment. Ultimately, the environment that you will be treated in. With relation to contracting the COVID-19 virus, it’s probably safer to go to the dentist than to the supermarket.

Gingivitis

Epidemiological data unequivocally confirms diabetes as a major risk factor for periodontitis. (This is also true for children and young adults). Uncontrolled diabetes being an even higher risk factor for periodontitis.

Periodontitis is a chronic inflammatory disease of the gums (gingiva), characterised by the destruction of the supporting bone structure around the teeth (periodontium). In most cases, periodontitis starts off as a mild, inflammatory disease, called gingivitis.

Gingivitis is characterised by the gums presenting signs of redness (erythema), swelling (oedema) and bleeding (haemorrhage), especially with brushing or flossing.

At this stage of the disease, the inflammation is limited to the gums and probably asymptomatic, or only with slight discomfort and possibility of bad breath (halitosis).

If treated, the gums can heal with no permanent damage to the bone structure around the teeth. With a good daily oral hygiene routine and regular visits to your dentist/hygienist, the gums can heal and you can prevent the reoccurrence of gingivitis.

If left untreated, gingivitis might develop into a more advanced gum disease, called periodontitis.

Periodontitis

Periodontitis is one of the leading causes of bad breath and is responsible for tooth mobility, with the ultimate result of tooth loss.

Unfortunately, lots of patients do not seek treatment while their gum disease is still in the early stages (gingivitis). By the time gingivitis has developed into periodontitis, it’s not possible to reverse the damage of the supporting bone structure around the teeth.

If you manage to get periodontal treatment in time, and if you are lucky enough to save some of your teeth, it will take great effort, discomfort and financial strain, to slow down periodontal disease.

In rare cases, you can arrest periodontal disease permanently. But even after periodontal disease is arrested, the damage to the supporting bone structure around the teeth is irreversible and will always be compromised.

Patients who had periodontal disease will always have a propensity to relapse. Reduced blood supply to the gums in a person living with diabetes, will always compromise present and future healing.

Link between hyperglycaemia and periodontal disease

There is a clear relationship between the degree of hyperglycaemia (high levels of glucose in the blood) and the severity of periodontal disease and even dental decay.

The mechanism that underpins the link between these two conditions are not completely understood. But, involve aspects of immune functioning, neutrophil activity (white blood cells responsible for healing damaged tissue and resolve infection) and cytokine biology (messaging network that regulates the immune system).

There is emerging evidence to support the existence of a two-way relationship between diabetes and periodontal disease. With diabetes increasing the risk of periodontal disease and periodontal disease negatively affecting glycaemic control.

Compared to diabetic individuals without severe periodontal disease, incidences of macroalbuminuria (protein albumin in urine – a risk factor for kidney and cardiovascular disease in diabetic individuals) increases two-fold in diabetic individuals with severe periodontal disease. End-stage renal disease increases three-fold in diabetic individuals with severe periodontal disease.

Furthermore, risk of cardio-renal mortality (ischaemic heart disease and diabetic nephropathy combined) is three times higher in diabetic individuals with severe periodontal disease than in diabetic individuals without severe periodontal disease.

Dry mouth

Dry mouth (xerostomia) is a common side effect of some chronic medication and often associated with diabetes. There is also a significant correlation between blood glucose levels and salivary glucose levels. Together, they pose a risk for fungal infections and higher incidence of tooth decay.

Oral hygiene treatment plan

If you don’t have an existing professional dental hygiene routine with a dentist/hygienist, book an assessment to discuss a treatment plan for your individual oral health needs.

It’s recommended that everybody has a professional cleaning at least twice a year and a dental examination at least once a year. Unless, it’s recommended otherwise by your dentist/hygienist.

A patient with underlying systemic health conditions will more likely require a professional dental cleaning every three to four months and daily oral hygiene instructions will be explained and monitored.

Your typical home routine will include brushing twice a day and interdental (between the teeth) cleaning by means of flossing, use of a waterpik and/or interdental brushes at least once a day. Oral hygiene instructions will vary, depending on your existing oral health and personal dental needs.

If you have existing inflammation which is characterised by bleeding of the gums when you brush and floss, you will need to have it seen to by a professional.

Chances are good that you have calcified plaque (calculus/tartar) build-up that is responsible for the inflammation and can’t be removed with your toothbrush and needs professionally intervention.

Remember, there is hardly any point in only brushing the teeth and not the gums  and not performing interdental care of some kind.

In addition, the application of fluoride and the use of a therapeutic mouth rinse might be advised by your dentist/hygienist. This needs to happen with caution and not without consultation with your dentist/hygienist as some of these products should only be used for a recommended period of time. Long-term use of some products might have consequences.

Take care of your health

It’s always advisable to take good care of your health. Especially when an underlying systemic condition, like diabetes, is present. Right now, with a much higher risk of contracting COVID-19, keep the following in mind:

  • A healthy and nutritious diet and active lifestyle will help better manage your blood glucose levels, achieve target blood lipid levels and maintain healthy blood pressure and body weight.
  • A multivitamin supplement provides nutrients that your body needs for regular function. Vitamin D is believed to help improve the body’s sensitivity to insulin (the hormone responsible for regulating blood glucose levels). Thus reducing the risk of insulin resistance, which is often a precursor to Type 2 diabetes. Vitamin D also plays a key role in immune function.
  • Bright sunlight exposure is associated with a reduced risk of Type 2 diabetes and heart disease by lowering blood insulin and lipid levels.
  • Sleep plays an important role in healing and repair of your heart and blood vessels.
  • Drinking enough water helps maintain the balance of body fluids. The function of these bodily fluids includes digestion, absorption, circulation, creation of saliva, transportation of nutrients and maintenance of body temperature.
  • Fresh air has been shown to help digest food more effectively, improve blood pressure and heart rate, strengthen the immune system and reduce the risk of obesity.
  • Ongoing sleep deficiency is linked to an increased risk of heart-,  kidney disease, high blood pressure, diabetes and stroke.
  • Stress aggravates diabetes, raises blood glucose levels, activates fat cells, impairs glucose tolerance, increases insulin resistance and impacts blood pressure.
  • Nicotine increases cortisol levels, reducing B cell antibody formation and T cells’ response to antigens. Therefore having a harmful effect on the immune system. It also hardens and narrows the blood vessels, curbing blood flow around the body. Together, making you more susceptible to infection, damage of the lungs and puts you at higher risk for heart disease.

Stay positive and nurture the spirit

Similarly, the mind has great power to influence the body. Knowledge of how to manage your diabetes and prevent complications is an important first step. But, understanding how to stay positive and nurture the spirit can also help in a holistic approach to diabetes care.

Managing diabetes is a lifelong commitment and that includes proper dental care. Your efforts will be rewarded with a lifetime of healthy teeth and gums.

MEET THE EXPERT


Sarie Liebenberg is an oral hygienist in private practice in Sandton, Gauteng with almost 30 years’ experience in dentistry. She is involved in various aspects of the dental industry, including lecturing, speaking and presenting on oral health. 


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Post-transplant diabetes mellitus

Dr Riaan Flooks, a nephrologist, helps us understand what post-transplant diabetes mellitus (PTDM) is and how it develops.


Chronic kidney disease

Chronic kidney disease (CKD) is quite common. This is when kidneys are damaged and can’t filter blood the way they should. Renal (kidney) transplantation is one of the treatment modalities thereof. The leading cause of CKD, worldwide, is said to be diabetes mellitus.

Kidney transplants

In 1964, it was recognised that hyperglycaemia (high-blood glucose) developed in some of the renal transplanted patients.

In South Africa, the first kidney transplants took place on 25 August 1966. But because of the lack of well-designed immunosuppressants, these transplants succumbed due to organ rejection.

Post-transplant diabetes mellitus (PTDM) is associated with increase in hospitalisations and deaths and is also known to cause cardiovascular disease and infections. The latter two conditions are also the leading causes of death in the transplant population.

History

After a meeting in 2003, guidelines were published that changed Transplant-Related Hyperglyceamia to New-Onset Diabetes After Transplantation (NODAT).

In 2014, new and updated guidelines were published, which renamed the disease: post-transplant diabetes mellitus.

Post-transplant diabetes mellitus 

This disease entity describes the presence of diabetes after transplantation, irrespective of the timing of diagnosis, or having had undetected elevated blood glucose levels prior to transplantation.

Some patients may develop elevated blood glucose levels immediately after the transplant, or soon thereafter. This group of patients would be referred to as having Transient Hyperglycaemia and is excluded from PTDM.

PTDM occurs in 4-25% of kidney recipients, and the variation is due to definition, duration of follow-up and the presence of risk factors for developing hyperglycaemia.

Risk factors for developing PTDM

The risk factors that predisposes to the development of PTDM has been grouped into two groups.

Traditional risk factors

Not forgetting that patients who are subjected to renal transplants may have the traditional risk factors that predisposes the general population to develop DM. These risk factors would include advanced age (>40yrs), obesity (BMI>30), Black race, a history of diabetes during pregnancy and a positive family history of DM.

Transplant-related risk factors

The second group of risk factors are referred to as transplant-related risk factors. They include immunosuppressive therapy, infections, impaired glucose tolerance and peri-operative hyperglycaemia and human leukocyte mismatching.

  • Immunosuppressive drugs

Not all immunosuppressive drugs are known to contribute to the development of PTDM. Only the diabetogenic drugs are discussed below:

  1. Glucocorticoids/Steroids

These drugs have an effect on the production of glucose in the liver and it also reduces glucose uptake in fat cells. Higher doses of glucocorticoids in these patients has been associated with the development of PTDM.

  1. Calcineurin Inhibitors (tacrolimus and cyclopsorine)

Patients on tacrolimus have a higher chance of developing PTDM. Patients with higher tacrolimus drug levels (>15ng/mL) have a higher chance to develop PTDM.

Both these drugs are toxic to the pancreatic cells (reduces insulin secretion and makes cells resistant to the effects of insulin), and thus causes PTDM to develop.

  1. Sirolimus

This drug is also known to cause diabetes.

  • Infections

There are certain infections that predisposes the recipients to develop PTDM. These infections would be hepatitis C and Cytomegalovirus (CMV).

  1. Hepatitis C is primarily a liver disease, which causes liver dysfunction and also causes pancreatic cell dysfunction. For these two latter reasons, this infection results in hyperglycaemia.
  2. CMV infection is also known to cause PTDM.

Patients who have impaired glucose tolerance (glucose level is elevated, but not high enough to make a diagnosis of DM) before transplantation are also more prone to develop PTDM. Patients who develop hyperglycaemia around the time of the transplantation are also at risk of developing PTDM.

Clinical relevance

PTDM is associated with the development of cardiovascular disease, and thus an increase in mortality. Studies have also shown that patients who had diabetes before the transplant compared to those who develop PTDM have an even higher cardiovascular mortality rate.

Although newer immunosuppressive therapies have improved allograft survival, the development of PTDM decreases the long-term allograft survival.

It is postulated that the recipients who develop PTDM, may be due to diabetic nephropathy (diabetic kidney disease) or the early efforts to reduce the diabetogenic immunosuppressants, which then lead to rejection.

PTDM is also associated with more frequent infections; the infections that seem to occur more commonly is CMV, urinary tract infections and lower respiratory tract infections.

Diagnosing PTDM

Elevated blood glucose levels are commonly seen in the peri-operative time period, and is related to surgical stress and the use of high-doses of steroid therapy that forms part of the induction therapy.

This is referred to as transient post-transplant hyperglycaemia, and can last up to six weeks. Thus, a diagnosis of PTDM should not be made within the first six weeks, post-transplantation. This group of patient is also at an increased risk of developing PTDM at a later stage.

The blood glucose level should be monitored weekly for the first four-six weeks post-transplantation and then at three months and six months.

To diagnose a patient with PTDM, you would prefer to have a non-acutely ill patient, who is stable on immunosuppressants and whose transplanted kidney is having stable renal function.

Diagnosis requires the same symptoms that is seen in non-transplanted diabetic, in combination with a biochemically proven hyperglycaemia.

The symptoms usually include: excessive thirst, excessive hunger, unintentional weight loss and excessive urination. These symptoms usually occur in combination with a random blood glucose level of ≥11,1mmol/L. The diagnosis can also be made by having a fasting blood glucose of ≥7mmol/L.

The HbA1c can also be used as a marker of glucose control after the first three months post-transplantation.

Management

The current treatments available include oral hypoglycaemic agents and insulin therapy. Adjustment of the immunosuppressive therapy should also be considered, but it should be weighed against the possibility of the recipient suffering an acute rejection episode.

Conclusion

Post-transplant recipients have similar complications as the non-transplanted diabetics. Immunosuppressive therapy has become more sophisticated and has improved long-term graft survival, but some of them still has diabetogenic effect. Also, with the change in the field of diabetes management, the treatment of PTDM has become slightly easier.

Read Jordan Barber’s story of developing post-transplant diabetes mellitus after a kidney transplant. 

MEET THE EXPERT


Dr Riaan Flooks is a practising nephrologist at Bloemfontein Mediclinic. His interests include ICU Nephrology, Diabetic Kidney Disease, Hypertension and Transplant Medicine. He forms part of the Transplant Team in the Free State Province, and is an active member of the Bloemfontein Mediclinic Medical Board.


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