Overlap of diabetic ketoacidosis and hyperosmolar hyperglycemic state

Abstract

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity. Despite major advances, reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging. A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle. It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution. Worldwide, there is a lack of large-scale studies that help define how hyperglycemic crises should be managed. This article will provide a comprehensive review of the pathophysiology, diagnosis, and management of DKA-HHS overlap.

Cemiplimab-Induced Hyperosmolar Hyperglycemic State With Concurrent Diabetic Ketoacidosis in a Patient Receiving Treatment for Cutaneous Squamous Cell Carcinoma

“…While the pathophysiology underlying DKA and HHS are distinct, growing evidence suggests an overlap of clinical findings in select cases. DKA typically occurs in T1DM whereas HHS typically occurs in T2DM [ 13 ]. In DKA, reduced insulin production due to various factors such as ICIs, infection, and autoimmunity leads to an increase in counter-regulatory hormones (growth hormone, catecholamines, glucagon, and cortisol), which triggers hepatic gluconeogenesis, glycogenolysis, and lipolysis [ 14 ].…”

“…In HHS, insulin resistance due to various factors such as obesity, stress such as surgery, and an acute illness can also lead to an increase in counter-regulatory hormones, precipitating hyperglycemia. However, two major differences between HHS and DKA have been noted: insulin levels in HHS are high enough to inhibit lipolysis/ketogenesis, and dehydration caused by osmotic diuresis is more severe leading to serum hyperosmolality [ 13 ]. Thus, HHS is characterized by severe hyperglycemia (blood glucose ≥600 mg/dL), plasma osmolarity >320 mOsm/kg, and no appreciable ketonemia or metabolic acidosis [ 15 ].…”

Manejo Do Estado Hiperosmolar Hiperglicêmico No Diabetes Mellitus Em Pacientes Adultos

“…Se o sódio sérico estiver normal ou elevado, usa-se uma solução hipotônica (como NaCl 0,45%), e se estiver elevado, usa-se uma isotônica ( NaCl 0,9%). A osmolalidade sérica precisa ser acompanhada a cada 1 ou 2 horas, de forma que não deve haver uma redução maior que 3 mOsm/kg/h para evitar eventos neurológicos (HASSAN et al, 2022;GERSHKOVICH et al, 2019).…”

“…Quanto à reposição dos eletrólitos, tem-se que o valor desejável de potássio vai de 4,0 a 5,0 mEq/L, sob essa ótica, recomenda-se repor potássio quando os níveis estão abaixo de 5,5 mEq/L, tendo em vista que em situações de desidratação como a EHH há uma depleção de potássio corporal mesmo com os níveis séricos estão elevados ou normais (agravada pelo fato de que a insulina reduz o potássio sérico). Nesses casos, faz-se uma infusão de potássio a 20-30 mEq/L; e se estiver abaixo de 3,5 mEq/L, faz-se uma infusão de 20-40 mEq/L por hora (HASSAN et al, 2022;BALDRIGHI et al, 2018). Se o magnésio estiver abaixo da normalidade, isso implicará em uma maior perda renal de potássio, logo, ele deve ser reposto na forma de sulfato de magnésio IV.…”

Mixed diabetic ketoacidosis and hyperglycemic hyperosmolarity in a girl with nephronophthisis 4 presenting with rhabdomyolysis and pancreatitis

“…2) The combination of DKA with HHS is associated with increased mortality and treatment difficulty. 3) We present a case report of a 16yearold female who had no medical problems except obesity and who was admitted to the hospital with severe DKA with HHS as the first manifestation of diabetes mellitus. She presented with severe metabolic acidosis, renal failure, rhabdomyolysis, pancreatitis, and coccyx sore.…”