1/9. hypoglycemia due to nateglinide administration in diabetic patient with chronic renal failure.A 56-year-old woman with diabetic triopathy, rheumatoid arthritis and chronic renal failure was admitted for severe hypoglycemic coma. arthralgia had been deteriorating for 6 months. Therefore, 5 mg of prednisolone was administered. Postprandial blood glucose (PPG), however, elevated from 260 to 290 mg/dl, although fasting blood glucose (FBG) levels ranged from 80 to 110 mg/dl. Three months after, 270 mg of nateglinide was given in addition to acarbose. After 2 days, hypoglycemia occurred at 02:00 h. Nateglinide was then decreased to 180 mg (before breakfast and lunch). After 5 days, hypoglycemia re-occurred at 01:00 h. Nateglinide was subsequently decreased to 90 mg before breakfast. The PPG levels ranged from 130 to 150 mg/dl. hypoglycemia did not occur during the next 2 months. On admission, FBG; 59 mg/dl, fasting immunoreactive insulin; 34 microU/ml, indicated hyperinsulinemic hypoglycemia. We administered 20 g of glucose intravenously, however, hypoglycemia recurred 4 times and 20 g of glucose was then administered. Although the plasma nateglinide level decreased, the nateglinide metabolite, N-[trans-4-(1-hydroxy-1methylethyl)-cyclohexanecarbonyl]-D-phenylalanine levels still had not decreased 29 h after nateglinide administration. Therefore, chronic renal failure appeared to alter the pharmacokinetic parameters of the nateglinide metabolite, which had accumulated by chronic renal failure. The nateglinide metabolite caused severe hypoglycemia in this case.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
2/9. Conversion to sirolimus: a successful treatment for posttransplantation Kaposi's sarcoma.The increased incidence of Kaposi's sarcoma (KS) in organ transplantation has been related to the KS herpesvirus and the permissive effect of immunosuppressive therapy. calcineurin inhibitors are the cornerstone of immunosuppression in organ transplantation, although they could promote tumor progression. In contrast, sirolimus, a new immunosuppressive agent, exhibits potent antitumor activity. We postulated that conversion from cyclosporine to sirolimus in patients with KS could favor regression of KS lesions without increasing the risk of graft rejection. Two renal transplant recipients with KS underwent conversion from cyclosporine to sirolimus. Both patients showed complete regression of KS lesions and excellent clinical and functional results. sirolimus offers a new and promising approach to the management of posttransplantation KS and probably to other types of malignancies in organ transplant recipients.- - - - - - - - - - ranking = 5keywords = coma (Clic here for more details about this article) |
3/9. Targeting metastatic leiomyosarcoma by rapamycin plus gemcitabine: an intriguing clinical observation.The emerging anti-cancer approach is based on combining a 'traditional' cytotoxic drug with a 'signaling' blocking agent. Such combination, if designed and applied properly, may increase selectivity towards tumor cells. The use of such combinations requires smart planning and choice of the drugs to be combined, their proper dosing as well as correct sequence and schedule of application. The combination of the anti-metabolite gemcitabine and the mTOR blocker, rapamycin, has achieved an impressive response in a patient with metastatic leiomyosarcoma.- - - - - - - - - - ranking = 5keywords = coma (Clic here for more details about this article) |
4/9. Nonketotic hyperosmolar coma in a patient with type 1 diabetes-related diabetic nephropathy: case report.Nonketotic hyperosmolar coma (NHC) is characterized by severe hyperglycemia; absence of, or only slight ketosis; nonketotic acidosis; severe dehydration; depressed sensorium or frank coma; and various neurologic signs. This condition is uncommon in type 1 diabetes. Because of little or no osmotic diuresis in patients with diabetic nephropathy, increases in plasma osmolality and therefore the likelihood of neurologic symptoms are limited. A 20-year-old male patient with type 1 diabetes with chronic kidney disease on conservative treatment (glomerular filtration rate [GFR], 18 mL/dk) presented with acute nonketotic hyperosmolar syndrome. The patient was admitted presenting with thirst, fatigue, and drowsiness. Blood biochemistry levels were urea 87 mg/dL, creatinine 5.09 mg/dL, glucose 830 mg/dL, glycosylated hemoglobin (HbA1c) 8%, C peptide <0.3 ng/mL, sodium 131 mmol/L, chloride 93 mmol/L, potassium 5.2 mmol/L, and calculated serum osmolality 385 mOsm/kg. The presumptive diagnosis on admission was nonketotic hyperosmolar syndrome precipitated by urinary infection. This is the first case report of hyperosmolar coma in a patient with type 1 diabetes with chronic kidney disease.- - - - - - - - - - ranking = 7keywords = coma (Clic here for more details about this article) |
5/9. The use of continuous hemodiafiltration in a patient with diabetic ketoacidosis.A variety of fatal complications are associated with diabetes mellitus. Among these, diabetic ketoacidosis (DKA) figures largely in fatalities in young diabetics. Although hyperosmotic diuresis in DKA causes extreme fluid loss, acute renal failure is less common than expected in DKA. We treated a case of severe DKA with associated coma, acute respiratory failure, and acute renal failure in a 24-year-old man who had been diagnosed with type 1 diabetes mellitus at age 19. The comatose patient had been intubated before transfer to our hospital for intensive care. Despite infusion with isotonic saline and insulin, metabolic acidosis was refractory. On day 2, urine output decreased and pulmonary congestion developed, so we started continuous veno-venous hemodiafiltration (CVVHDF), which was effective against the metabolic acidosis; urine output increased gradually. CVVHDF was withdrawn on day 7, and the patient's renal function recovered completely. He was discharged from the intensive care unit (ICU) on day 14.- - - - - - - - - - ranking = 2keywords = coma (Clic here for more details about this article) |
6/9. Unusual renal involvement during diabetic ketoacidosis (DKA) in a newly diagnosed type I diabetic child.A 10-year-old boy, in a precomatose state, was admitted to our Endocrine Unit for diabetic ketoacidosis. It took unusually long to reequilibrate the acidosis despite a bicarbonate drip. On the 4th day the patient suddenly complained of an acute abdominal pain associated with macrohematuria and oliguria; ankle edema was evident. No radio-opaque image was detected along the urinary tract. An intravenous pyelogram (IVP) showed an almost totally silent left kidney. Ten days later a control IVP showed complete normality of both kidneys. We postulated that the serious and protracted dehydration might have resulted in the formation of a blood clot along the renal tract and that the rehydration may have subsequently removed it.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
7/9. Normo-osmolar, nonketotic, hyponatremic diabetic syndrome associated with impaired renal function.A case is reported of a nonketotic woman with diabetes who presented with a blood glucose of 72.8 mmol/L (1310 mg/dl), plasma sodium of 92 mmol/L, normal osmolality, impaired renal function, and alert clinical state. Before the implication of the unusual nature of the metabolic disturbance was fully considered, the initial treatment was with a rapid infusion of saline. On consideration, however, it was postulated that as her hyperglycemia had developed, the expected osmotic diuresis was prevented by the impairment of her renal function. This had allowed compensatory hyponatremia to develop to maintain normal osmolality and protect the patient from coma. The high-dose saline infusion was stopped, and she was successfully treated with insulin and potassium but only minimal saline. The use of large quantities of saline in normo-osmolar, nonketotic, hyponatremic diabetic syndrome associated with impaired renal function and alert mental state is unnecessary and potentially dangerous.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
8/9. Hypoglycemic coma due to disopyramide toxicity.disopyramide (Norpace) is a widely used, generally well tolerated antiarrhythmic agent. We have described an 82-year-old patient with non-insulin-dependent diabetes mellitus and renal insufficiency who had hypoglycemic coma and obstructive uropathy due to disopyramide therapy.- - - - - - - - - - ranking = 5keywords = coma (Clic here for more details about this article) |
9/9. Para-aminosalicylic acid-induced hypoglycaemia in a patient with diabetic nephropathy.A 62-year-old Indian with diabetic nephropathy controlled with metformin, developed miliary tuberculosis for which he was treated with rifampicin, isoniazid and ethambutol. Soon afterwards he developed cholestatic hepatitis and visual disturbance. Rifampicin and ethambutol were stopped. streptomycin caused vertigo and had to be stopped. The introduction of para-aminosalicylic acid (PAS) led to hypoglycaemic coma. metformin was stopped. Hypoglycaemic coma recurred. PAS was stopped and the patient's blood glucose concentrations became normal. Treatment with isoniazid and ethambutol led to total recovery from pulmonary tuberculosis. The induction of hypoglycaemia with PAS in this patient suggests a potential role for PAS in the treatment of diabetes mellitus.- - - - - - - - - - ranking = 2keywords = coma (Clic here for more details about this article) |