Abbreviations: AaO 2 , alveolar-to-arteriolar oxygen; AKA, alcoholic ketoacidosis; ARDS, adult respiratory distress syndrome; BUN, blood urea nitrogen; CPT, carnitine palmitoyl-transferase; CSF, cerebrospinal fluid; DKA, diabetic ketoacidosis; FFA, free fatty acid; HHS, hyperosmolar hyperglycemic state; IRI, immunoreactive insulin; PaO 2 , arteriolar partial pressure of oxygen; RDKA, recurrent DKA.A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Management of Hyperglycemic Crises in Patients With Diabetes T E C H N I C A L R E V I E R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t s 132DIABETES CARE, VOLUME 24, NUMBER 1, JANUARY 2001Technical Review noted in newly diagnosed obese type 2 diabetic patients (5,26,31). Therefore, the concept that the presence of DKA in type 2 diabetes is a rare occurrence is incorrect.The most common types of infections are pneumonia and urinary tract infection, accounting for 30-50% of cases (Table 4). Other acute medical illnesses as precipitating causes include alcohol abuse, trauma, pulmonary embolism, and myocardial infarction, which can occur both in type 1 and 2 diabetes (6). Various drugs that alter carbohydrate metabolism, such as corticosteroids, pentamidine, sympathomimetic agents, and ␣-and ␤-adrenergic blockers, and excessive use of diuretics in the elderly may also precipitate the development of DKA and HHS.The recent increased use of continuous subcutaneous insulin infusion pumps that use small amounts of short-acting insulin has been associated with an incidence of DKA that is significantly increased over the incidence seen with conventional methods of multiple daily insulin injections, in spite of the fact that most of the mechanical problems with insulin pumps have been resolved (6,(32)(33)(34). In the Diabetes Control and Complications Trial, the incidence of DKA in patients on insulin pumps was about twofold higher than that in the multipleinjection group over a comparable time period (35). This may be due to the exclusive use of short-acting insulin in the pump, which if interrupted leaves no reservoir of insulin for blood glucose control.Psychological factors and poor compliance, leading to omission of insulin therapy, are important precipitating factors for recurrent ketoacidosis. In young female patients with type 1 diabetes, psychological problems complicated by eating disorders may be contributing factors in up to 20% of cases of recurrent ketoacidosis (36,37). Factors that may lead to insulin omission in younger patients include fear of weight gain with good metabolic control, fear of hypoglycemia, rebellion against authority, and stress related to chronic disease (36). Noncompliance with insulin therapy has been found to be the leading precipitating cause for DKA in urban African-Americans and medically indigent patients (5,26). In addition, a recent study showed that diabetic patients without health insurance or with Medicaid alone had hospitali...

The appropriate target for BP in patients with CKD and hypertension remains uncertain. We report prespecified subgroup analyses of outcomes in participants with baseline CKD in the Systolic Blood Pressure Intervention Trial. We randomly assigned participants to a systolic BP target of <120 mm Hg (intensive group; =1330) or<140 mm Hg (standard group; =1316). After a median follow-up of 3.3 years, the primary composite cardiovascular outcome occurred in 112 intensive group and 131 standard group CKD participants (hazard ratio [HR], 0.81; 95% confidence interval [95% CI], 0.63 to 1.05). The intensive group also had a lower rate of all-cause death (HR, 0.72; 95% CI, 0.53 to 0.99). Treatment effects did not differ between participants with and without CKD ( values for interactions ≥0.30). The prespecified main kidney outcome, defined as the composite of ≥50% decrease in eGFR from baseline or ESRD, occurred in 15 intensive group and 16 standard group participants (HR, 0.90; 95% CI, 0.44 to 1.83). After the initial 6 months, the intensive group had a slightly higher rate of change in eGFR (-0.47 versus -0.32 ml/min per 1.73 m per year; <0.03). The overall rate of serious adverse events did not differ between treatment groups, although some specific adverse events occurred more often in the intensive group. Thus, among patients with CKD and hypertension without diabetes, targeting an SBP<120 mm Hg compared with <140 mm Hg reduced rates of major cardiovascular events and all-cause death without evidence of effect modifications by CKD or deleterious effect on the main kidney outcome.

Background An estimated 4 million Americans have been exposed to the hepatitis C virus (HCV) in the US population. The risk of incident and progressive chronic kidney disease and of mortality in patients with normal kidney function infected with HCV is unclear. Methods In a nationally representative cohort of 100,518 HCV+ and 920,531 HCV- US Veterans with normal baseline estimated glomerular filtration rate(eGFR), we examined the association of HCV infection with: (1)all-cause mortality, (2)incidence of decreased kidney function (defined as eGFR <60 ml/min/1.73m2 and 25% decrease in eGFR), (3)ESRD, and (4)rate of kidney function decline. Associations were examined in naïve and adjusted Cox models (for time-to-event analyses) and logistic regression models (for slopes), with sequential adjustments for important confounders. Propensity-matched cohort analysis was used in sensitivity analyses. Results The patients’ age was 54.5±13.1(mean±SD) years, 22% were black and 92% male, and the baseline eGFR was 88±16 ml/min/1.73m2. In multivariate adjusted models HCV infection was associated with 2.2 fold higher mortality (fully adjusted hazard ratio(aHR), 95%CI: 2.17(2.13–2.21)), 15% higher incidence of decreased kidney function(aHR, 95%CI: 1.15(1.12–1.17)), 22% higher risk of steeper slopes of eGFR (adjusted odds ratio, 95%CI: 1.22(1.19–1.26)) and 98% higher hazard of ESRD (aHR, 95%CI: 1.98 (1.81–2.16)). Quantitatively similar results were found in propensity-matched cohort analyses. Conclusions HCV infection is associated with higher mortality risk, incidence of decreased kidney function and progressive loss of kidney function. Randomized controlled trials are warranted to determine whether treatment of HCV infection can prevent the development and progression of CKD and improve patient outcomes.

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National Institutes of Health.

Registered at ClinicalTrials.gov with study number NCT01206062.

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Background and objectives Hypertension is the most important treatable risk factor for cardiovascular outcomes. Many patients with CKD are elderly, but the ideal BP in these individuals is unknown.Design, setting, participants, & measurements From among 339,887 patients with incident eGFR,60 ml/min per 1.73 m 2 , we examined associations of systolic BP (SBP) and diastolic BP (DBP) with all-cause mortality, incident coronary heart disease (CHD), ischemic strokes, and ESRD from the time of developing CKD until the end of follow-up (July 26, 2013, for mortality, CHD, and stroke, and December 31, 2011, for ESRD) in multivariableadjusted survival models categorized by patients' age.Results Of the total cohort, 300,424 (88%) had complete data for multivariable analysis. Both SBP and DBP showed a U-shaped association with mortality. SBP displayed a linear association with CHD, stroke, and ESRD, whereas DBP showed no consistent association with either. SBP.140 mmHg was associated with higher incidence of all examined outcomes, but with an incremental attenuation of the observed risk in older compared with younger patients (P,0.05 for interaction) The adjusted hazard ratios and 95% confidence intervals associated with SBP$170 mmHg (compared with 130-139 mmHg) in patients ,50, 50-59, 60-69, 70-79, and $80 years were 1.95 (1.34 to 2.84), 2.01 (1.75 to 2.30), 1.68 (1.49 to 1.89), 1.39 (1.25 to 1.54), and 1.30 (1.17 to 1.44), respectively. The risk of incident CHD, stroke, and ESRD was incrementally higher with higher SBP in patients aged ,80 years but showed no consistent association in those aged $80 years (P,0.05 for interaction for all outcomes). ConclusionsIn veterans with incident CKD, SBP showed different associations in older versus younger patients. The association of higher SBP with adverse outcomes was present but markedly reduced in older individuals, especially in those aged $80 years. Elevated DBP showed no consistent association with vascular outcomes in patients with incident CKD.