Metabolic complications of Diabetes

Question 1

list the 3 clinical signs of diabetic ketoacidosis

Answer 1

Hyperglycaemia
ketosis (+ve)- elevated ketone in blood or urine
metabolic acidosis (high pH and low Bicarbonate)

Question 2

what is the normal response to hyperglycaemia ?

Answer 2

Increase in insulin production by Beta cells, leads to increased glucose uptake by fat, muscle and liver

Reduced glucagon production by alpha cells, which reduces gluconeogenesis and glycogenolysis

Question 3

describe how osmotic diuresis occurs in DKA

Answer 3

glucose and ketones are freely filtered at glomerulus
SGLT2 transporters are fully saturated because maximal glucose reabsorption threshold is reached
Increased glucose concentration in tubular lumen creates an osmotic gradient which draws water into the lumen

Question 4

describe how K depletion occurs in DKA

Answer 4

Loss in blood volume causes RAAS system to kick in and there is increased aldosterone production. Hyperaldosteronism leads to more Na reabsorption and K excretion.

Question 5

Describe the mechanism of DKA in response to insulin deficiency

Answer 5

Insulin deficeincy:
Promotes lipolysis (breakdown of TGs which leads to inc ketones)
promotes proteolysis (makes amino acids )
Increased gluconeogenesis and glycogenolysis
–> increased Ketone production and academia
–> leads to vomiting

blocks glucose uptake in peripheral tissues

• -> leads to hyperglycaemia
• -> causes osmotic diuresis

Question 6

describe treatment for DKA

Answer 6

Treatment for:
hypovolaemia = IV fluid
insulin deficiency = IV insulin
Hypokalaemia = IV potassium

Question 7

what is required along with IV potassium treatment ?

Answer 7

Cardiac monitoring

Question 8

describe how Hyperosmolar Hyperglycaemic state differs from DKA?

Answer 8

HHS is a complication of DM which causes profound osmotic diuresis and hyperglycaemia without ketoacidosis (so no lipolysis)

Question 9

how dies the osmotic diuresis seen in HHS differ from that seen in DKA?

Answer 9

in HHS, it is much more profound hypovolaemia but a longer and more insidious onset

Question 10

describe treatment for HHS and how does it differ from DKA?

Answer 10

Same as DKA BUT start off with IV insulin until blood glucose is stable and then add IV insulin

Question 11

why is K excretion less pronounced in HHS compared to DKA?

Answer 11

Because they usually have chronic renal impairment so patients would be less Able to excrete K

Question 12

which condition is commonly seen in HHS due to the presence of hypergycameia ?

Answer 12

Venous thrombosis due to hypercloaguable blood due to hyperglycaemia

Question 13

List the differences between DKA and HHS in:
history
patient age
type of diabetes 
insulin production
patient alertness
clinical features

Answer 13

DKA:
short history 
patient age < 65
Type 1 DM
Absolute insulin deficiency 
patient usually alert
Hyperglycaemia
Dehydration
ACIDOSIS

HHS:
insidious history 
patient age > 65
Type 2 DM
relative insulin deficiency (some produced)
patient often drowsy/confused
profound hyperglycaemia 
NO acidosis
significant dehydration and hypernatraemia

Question 14

list the initial symptoms of hypoglycaemia

Answer 14

Sweating 
Tremor
Palpitations 
Hunger
Anxiety

Question 15

What are the late symptoms of Hypoglycaemia?

Answer 15

glucose shortage in brain leading to confusion and impaired consciousness

Question 16

Describe the treatment of mild and severe hypoglycaemia

Answer 16

Mild:
15-20g fast acting carbohydrate

Severe:
15-20g fast acting carbohydrate
if reduced consciousness:
IM glucose and IV dextrose