Endo - DKA, Addison's Disease, Primary and Secondary Hyperaldosteronism

Question 1

DKA - what is it?

Answer 1

It is when excess glucose cannot be removed due to lack of insulin, therefore glucose is not taken up by cells to be metabolised

Instead uncontrolled lipolysis occurs, which results in free fatty acids, that are then converted to ketone bodies

This then leads to severe acidosis and hyperglycaemia

Question 2

DKA - which diabetes does it occur mainly in?

Answer 2

Mainly Type 1 DM

Question 3

DKA - what are the most common precipitating triggers?

Answer 3

1. Missed insulin dose
2. Infection
3. Surgery
4. M.I.
5. Pancreatitis

Question 4

DKA - what is the clinical presentation?

Answer 4

1. Abdo pain
2. Polyuria, polydipsia
3. Pear drop smell on breath
4. Gradual drowsiness, vomiting and dehydration
5. Kussmaul respiration - deep and laboured breathing pattern

Question 5

DKA - what are the blood components you test for and what result is indicative of DKA?

Answer 5

1. Glucose >11mmol/L or known DM
2. pH <7.3
3. Bicarbonate <15mmol/L
4. Ketones >3mmol/L or ketones + + on dipstick

Question 6

DKA - what is the management?

Answer 6

FIGPICK
Fluids - 1L isotonic saline in 1st hour, then add K+ every 2 to 4h after
IV Insulin - 0.1unit/kg/hr infusion
Glucose - start when at least <14mmol/L alongside saline to avoid hypos
Potassium replacement - never infuse >10mmol hour
Infection
Chart fluid balance
Ketones - monitor

Question 7

DKA - when is DKA defined as being resolved?

Answer 7

When:

pH >7.3

blood ketones < 0.6 mmol/L

bicarbonate > 15.0mmol/L

Question 8

DKA - what are the complications due to incorrect fluid therapy

Answer 8

Iatrogenic due to incorrect fluid therapy: cerebral oedema, hypokalaemia, hypoglycaemia

Cerebral oedema - especially in kids and young adults

Question 9

DKA - what are some complications?

Answer 9

ARDS

AKI

Thromboembolism

Question 10

Addison’s Disease - what is it?

Answer 10

Also called PRIMARY ADRENAL INSUFFICIENCY

Autoimmune destruction of the adrenal cortex, causing less aldosterone and cortisol to be produced

Leads to primary hypoadrenalism

Question 11

Addison’s Disease - what are the causes?

Answer 11

Autoimmune (80%)

TB - most common cause worldwide

Adrenal metastases

HIV

Question 12

Addison’s Disease - what are the symptoms?

Answer 12

Bronze skin

G.I. - Abdo pain, constipation

MSK - weakness, myalgias

NEURO - dizzy, syncope

PSYCH - tearful, anorexia

Question 13

Addison’s Disease - what are the signs?

Answer 13

Pigmented buccal mucosa

Vitiligo

Postural hypotension

Shock

Question 14

Addison’s Disease - what are the investigations?

Answer 14

Definite investigation:

1. ACTH stimulation test. Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM
2. AD excluded if 30

If ^^^ not readily available - 9am serum cortisol test

Question 15

Addison’s Disease - what are the electrolyte imbalances seen?

Answer 15

HYPOGLYCAEMIA - due to low cortisol, because cortisol is responsible for breaking down glycogen into glucose

HYPONATRAEMIA

HYPERKALAEMIA

Question 16

Addison’s Disease - what is the management?

Answer 16

Given combination of:

Used to replace cortisol
1. HYDROCORTISONE - 20-30mg daily

Used to replace aldosterone
2. FLUDROCORTISONE - to correct postural hypotension

Question 17

Secondary adrenal insufficiency - what is it and what are the causes

Answer 17

Secondary adrenal insufficiency caused by inadequate ACTH stimulating the adrenal glands, results in decreased cortisol being released.

Usually result of loss or damage to the pituitary gland.

Due to congenital underdevelopment (hypoplasia) of the pituitary gland, surgery, infection, loss of blood flow or radiotherapy.

Question 18

Primary Hyperaldosteronism (Conn’s syndrome) - what is it?

Answer 18

Primary Hyperaldosteronism is when too much aldosterone is produced, independent of the RAAS system

Question 19

Primary Hyperaldosteronism (Conn’s syndrome) - what is the levels of Renin like?

Answer 19

Serum renin is low as it is suppressed by high BP

Question 20

Primary Hyperaldosteronism (Conn’s syndrome) - what are the causes?

Answer 20

Adrenal adenoma - called Conn’s syndrome when this is the cause

Bilateral adrenal hyperplasia

Adrenal carcinoma - rare

Genetics - Familial hyperaldosteronism

Question 21

Primary Hyperaldosteronism (Conn’s syndrome) - symptoms and signs?

Answer 21

Often asymptomatic

Signs of hypokalaemia - weakness, cramps, polyuria

High BP

Question 22

Primary Hyperaldosteronism (Conn’s syndrome) - what investigations can you do?

Answer 22

Check renin and aldosterone levels and do a renin/aldosterone ratio
1. HIGH aldosterone and LOW renin - PRIMARY Hyperaldosteronism

2. HIGH aldosterone and HIGH renin - SECONDARY Hyperaldosteronism

Check K+ for hypokalemia
Blood gas analysis - alkalosis

Look for cause like adenoma so CT, MRI, renal doppler US

Question 23

Primary Hyperaldosteronism (Conn’s syndrome) - what is the management?

Answer 23

Hyperplasia - Aldosterone Antagonists, Spironolactone or Eplerenone

Conn’s - Spironolactone pre-op
Laparoscopic adrenalectomy

Adrenal carcinoma - surgery

Question 24

Primary Hyperaldosteronism (Conn’s syndrome) - what is Secondary Hyperaldosteronism?

Answer 24

It is where excessive renin stimulates excessive aldosterone production

Question 25

Primary Hyperaldosteronism (Conn’s syndrome) - Secondary Hyperaldosteronism causes?

Answer 25

Occurs due to kidney BP being lower than rest of body BP, so the juxtaglomerular cells detect low BP, therefore producing more renin, so causes of this include:

1. Renal artery stenosis
2. Renal artery obstruction
3. Heart Failure

Question 26

Primary Hyperaldosteronism (Conn’s syndrome) - Secondary Hyperaldosteronism investigations?

Answer 26

CT angiogram

Doppler US

Magnetic resonance angiography (MRA)

Question 27

Primary Hyperaldosteronism (Conn’s syndrome) - Secondary Hyperaldosteronism treatment?

Answer 27

Need to treat underlying cause

Renal artery stenosis - Percutaneous renal artery angioplasty via the femoral artery