Serum Tonicity, Extracellular Volume and Clinical Manifestations in Symptomatic Dialysis-Associated Hyperglycemia Treated Only with Insulin

Abstract

The absence of osmotic diuresis modifies the effects of hyperglycemia on body fluids in patients with advanced renal failure. To determine the relationship between clinical manifestations and abnormalities in tonicity and extracellular volume in such patients, we analyzed 43 episodes of severe dialysis-associated hyperglycemia (serum glucose exceeding 600 mg/dL) treated only with insulin. The main manifestations were dyspnea in 22 cases (pulmonary edema in 19), nausea and vomiting in 15, coma in 13 and seizures in 3, while 5 patients had no symptoms. Treatment with insulin resulted in a decrease in serum glucose value from 913 ± 197 mg/dL to 170 ± 78 mg/dL, an increase in serum sodium level from 125 ± 5 to 136 ± 5 mmol/L, and a fall in calculated serum tonicity value from 300 ± 13 to 282 ± 11 mmol/kg (all at p < 0.001). The ratio of the change in serum sodium level over change in serum glucose concentration was –1.50 ± 0.22 mmol/L per 100 mg/dL. The percent increase in extracellular volume secondary to hyperglycemia developing from the prior euglycemic state and calculated from changes in serum sodium and chloride concentrations, was 10.9% ± 4.6% (1.5% ± 0.6% per 100 mg/dL increase in serum glucose level). All clinical manifestations dissipated after correction of hyperglycemia in 42 patients. One woman developed during treatment a fatal myocardial infarction. Dialysis patients with severe hyperglycemia may develop symptoms as a result of hypertonicity and extracellular expansion. Insulin alone may be sufficient treatment for these symptoms. The changes in serum tonicity and electrolytes during treatment are consistent with theoretical predictions.

Abnormalities of serum potassium concentration in dialysis-associated hyperglycemia and their correction with insulin: review of published reports

“…in DH and compares them to representative reports of DKA and NKH occurring in patients with significant renal function. The main therapeutic difference between DH and hyperglycemia occurring in patients with preserved renal function is that insulin infusion is usually the only treatment needed to correct the fluid and solute abnormalities of DH [16][17][18]. The second purpose of this review was to analyze the published reports of the effects of insulin on serum K ?…”

Principles of Quantitative Fluid and Cation Replacement in Extreme Hyperglycemia

“…The provision for this use of corrected is that clinical observations should confirm Katz's theoretical calculation, which is based on a closed system without any changes in the external balance of monovalent cations or water. Observations in patients with end-stage renal disease, who, by and large, represent closed systems, confirmed Katz's number [19,[23][24][25][26]. An example of the effect of correction of anuric hyperglycemia on serum tonicity is shown below.…”

“…, and diabetic ketoacidosis (DKA) and nonketotic hyperosmolar hyperglycemia (NKH) in patients with preserved renal function [25]. In D-AH, the average corrected was slightly below the normal range of , because hyperglycemia causes thirst and fluid consumption, which is translated in weight gain [28][29][30], modestly depressed values of corrected and, in approximately one-third of the episodes, usually modest hypotonicity after correction of the hyperglycemia with insulin [24]. Severe hypertonicity, reported in the past in DAH episodes after dialysis with 7% dextrose dialysate, which is not available nowadays, has not been reported recently.…”

Hypertonicity: Clinical entities, manifestations and treatment

“…In the absence of any other change in solute and water balance in these patients, water intake driven by hyperglycemic thirst should lead to hyponatremia after correction of hyperglycemia even though [Na] S rises as [Glu] S decreases[49]. Hyponatremia after correction of severe hyperglycemia with insulin infusion and no other interventions was documented in approximately one third of the cases in patients on chronic dialysis[59]. …”