Hyperkalaemia after interruption of CSII

Diabetologia, Nov 1986

Dr. J. C. Pickup

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Hyperkalaemia after interruption of CSII

Diabetologia References Yours sincerely 0 1. ModanM, KarasikA, HalkinH, FuchsZ, LuskyA, ShitritA, Mo- 1 Dr. M. Modan 2 Yours sincerely, 3 Professor J. Barbosa, 4 0 M. Modan, A. Karasik and H. Halkin 1 danB (1986) Effect of past and concurrent body mass index on, prevalence of glucose intolerance and Type 2 (non-insulin-dependent) diabetes and on insulin response: the Israel study of glucose , intolerance obesity and hypertension. Diabetologia 29: 82-89, 2. Committee on Dietary Allowances Food and Nutrition Board , (1980) Recommended dietary allowances, 9th revised edn. National Academy of Sciences , p 24, 3. ModanM, Lubin F, ShitritA, LuskyA (1986) Habitual diet, physical activity, body mass index and glucose intolerance. The Israel, G O H Study,, Diabetes 35 [Suppl 1]: 74A 2 Department of Clinical Epidemiology , The Chaim Sheba , Medical Center , Tel Hashomer 52621 , Israel 3 J. Barbosa 4 Division of, Endocrinology and Metabolism, Department of Medicine, University of Minnesota , Minneapolis, Minnesota 55455 , USA 4) Logistic regression analysis is appropriate, as BMI was entered into the equation as a categorical variable, in three categories, where the rate in the two extreme ones is compared to the middle one. 5) Our questionnaire referred to all types of habitual activity, including work time as well as at leisure time. The rate of persons involved in any type of sport was minimal. "High" physical activity was defined as activity score in the highest tertile of the study group. The score consisted of the weekly number of hours spent in moderate activity (heavy activity was not reported by any of the 502 individuals constituting the subsample interviewed for dietary intake and physical activity) + half of the hours spent in light activity defined according to the Committee on Dietary Allowances [2]. Using this crude measure, and accounting for age, BMI and total caloric intake, the risk for Type 2 diabetes for "highly" active individuals of both sexes was 0.67 with 90% confidence limits 0.4%0.96 (p = 0.04) [3]. This was validated by significantly lower insulin response in the "highly" active individuals in all sex and BMI categories (unpublished data). - The editor apologizes for the inadvertent error made during the editing and production process of Dr. Modan's letter [Diabetologia (1986) 29:408]. Instead of "in both Type1 and Type2 diabetes" it should have been printed "in both diabetes categories", as originally submitted by Dr. Modan and her associates. The editor deeply regrets this technical error. Type I (insulin-dependent) diabetes and the question of heterogeneity Dear Sir, I read with interest the report entitled "HLA-DR3 is associated with a more slowly progressive form of Type I (insulin-dependent) diabetes" by Ludvigsson et al. [ 1 ]. Since many of those interested in the causes of Type I diabetes mellitus believe in the likelihood of genetic heterogeneity, studies attempting to correlate phenotypes with genetic markers are welcome and may shed light on this important question. Unfortunately, most, if not all, claims of such correlations have lacked adequate confirmation. This confusing state of affairs has involved age of onset and other clinical parameters, as well as immunological indicators such as islet cell antibodies, insulin antibodies, etc. The results of Ludvigsson et al. [ 1 ] seem to be in apparent conflict with data we reported recently [ 2 ] from cross sectional studies of serum C-peptide in Type 1 diabetic patients and their siblings. We found in this study that D R 4 + diabetic patients showed better preservation of their C-peptide blood concentrations than diabetic patients with other HLA types. It is difficult to reconcile these findings with the Ludvigsson et al. [ 1 ] results showing that DR3 + diabetic patients have a milder disease. Both our study [ 2 ] (not prospective) and the Ludvigsson et al. study [11(based on questionnaire data and multicenter) have weaknesses. Thus, this subject needs independent confirmation. The observation by Ludvigsson et al. [ 1 ] that 15patients were D R 4 - , DR3 - , D R 2 + , presumably mostly from France, is of considerable interest. We have recently shown that there is a third HLArelated susceptibility axis for diabetes (in addition to the DR3 - and D R 4 - related axes) defined by homozygous typing cells (Dw) and restriction fragment length polymorphisms which is part of Dtl2-LDMN2 as well as D R I - D w l haplotypes [ 3 ]. Those 15 patients presumably carried one or both of these haplotypes. Dear Sir, It has recently been suggested that the serum potassium concentrations on admission to hospital with ketoacidosis may be higher in patients treated by continuous subcutaneous insulin infusion (CSII) compared to those receiving conventional injection therapy [ 1 ]. In consideration of the possible risks of hyperkalaemia, it may be of interest to reconsider the study which we published in Diabetologia in 1982 [ 2 ], where CSII was deliberately interrupted for 9 h in 9 resting and fasting Type I (insulin-dependent) diabetic patients. We did not record plasma potassium levels at the time of the study, but we have now measured by flame photometry the values on the stored plasma samples (kept at - 40 °C) from the 7 C-peptide negative patients (all male, mean + SD age 33 + 12 years, duration of diabetes 13 + 6 years). Figure I shows the results, together with the changes in plasma glucose, blood 3-hydroxybutyrate and plasma free insulin concentration, which were assayed at the time of the study. Mean plasma potassium levels increased throughout the 9 h and were significantly different from baseline at all time points from 6 h (p < 0.01, t-test) until the end of the experiment (p < 0.01). Clearly, delayed measurement is not ideal, and small alterations in concentration by sublimation may have occurred; however, the values may be taken as a reassurance that dangerous hyperkalaemia is unlikely to occur after 9 h of withdrawal of pump therapy under these .a o L 5.2 5.0 4.4 3 1 < i I i i i i i I i i O 1 2 3 4 5 6 / 8 9 TIME (H) Announcements European Diabetes Epidemiology Study Group (EDESG) The next meeting of the EDESG will be held in Oxford, U K from 12-15 April 1987. The major topics for discussion are: (1) the importance of hypertension in the development of micro and macro angiopathy in diabetes; (2) the relationship of obesity to diabetes morbidity; (3) the relationship between nutritional factors, and in particular, protein intake and renal function in insulin-dependent diabetes. For further information contact: Dr. J. I. Mann, Department of Community Medicine and General Practice, Gibson Laboratories Building, Radcliffe Infirmary, Oxford OX2 6HE, UK. Tel.: (0865) 511293/4 conditions. The highest recorded plasma potassium value was 6.0 mmol/1 in one patient at 8 h. However, these results differ from those recently reported by Knight et al. [ 3 ],who employed a similar experimental protocol. These authors found that plasma potassium levels were not different after 8 h of pump disruption compared to baseline. Although the frequency of ketoacidosis during CSII is probably no greater than on injection therapy [ 4, 5 ], exercise, feeding and the stress of infection may exacerbate metabolic decompensation in these patients, who are already at risk because of the small subcutaneous reservoir of insulin during CSII. We must therefore remain alert to the potential dangers of accidental stoppage of CSII, and to the clinical and biochemical course of ketoacidosis in these patients. I thank my colleagues who helped in the original study and Peter Tutt, who performed the subsequent potassium measurements. References Diabetologia ( 1986 ) 29 : 824 - Letters to the Editor - Announcements 1. Knight G , Jennings AM , Boulton AIM , Tomlinson S , Ward JD ( 1985 ) Severe hyperkalaemia and ketoacidosis during routine treatment with an insulin pump . Br Med J 291 : 371 - 372 2. Pickup JC , Viberti GC , Bilous RW , Keen H , Alberti KGMM , Home PD , Binder C ( 1982 ) Safety of continuous subcutaneous insulin infusion: metabolic deterioration and glycaemic autoregulation after deliberate cessation of infusion . Diabetologia 22 : 175 - 179 3. Knight G , Blair P , Parker B , Senior S , Forrest ARW , Tomlinson S , Ward JD ( 1986 ) Potassium balance during insulin pump treatment and the effects on plasma potassium of an 8 h disruption of CSII. Diabetic Med (in press) 4. BendingJJ, PickupJC, Keen H ( 1985 ) Frequency of diabetic ketoacidosis and hypoglycaemic coma during treatment with continuous subcutaneous insulin infusion. Audit of medical care . Am J Med 79 : 685 - 691 5. Sonnenberg GE , Mfilhauser I , Chantelau E , Berger M ( 1985 ) Incidence of ketoacidosis and severe hypoglycaemia in conventionally and CSII treated type I diabetic patients . Diabetes 34 ( Suppl 1 ): 117A

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Dr. J. C. Pickup. Hyperkalaemia after interruption of CSII, Diabetologia, 1986, 823-824, DOI: 10.1007/BF00873227