Clinical Value of Continuous Blood Purification in the Treatment of Patients with Severe Heart Failure Complicated with Renal Failure

Aim. To assess prescribing practices of noninsulin antidiabetic drugs (NIADs) in T2DM with several major contraindications according to prescribing information or clinical guidelines: renal failure, heart failure, liver dysfunction, or history of bladder cancer.Methods. Cross-sectional, descriptive, multicenter study. Electronic medical records were retrieved from all T2DM subjects who attended primary care centers pertaining to the Catalan Health Institute in Catalonia in 2013 and were pharmacologically treated with any NIAD alone or in combination.Results. Records were retrieved from a total of 255,499 pharmacologically treated patients. 78% of patients with some degree of renal impairment (glomerular filtration rate (GFR) < 60 mL/min) were treated with metformin and 31.2% with sulfonylureas. Even in the event of severe renal failure (GFR < 30 mL/min), 35.3% and 22.5% of patients were on metformin or sulfonylureas, respectively. Moreover, metformin was prescribed to more than 60% of patients with moderate or severe heart failure.Conclusion. Some NIADs, and in particular metformin, were frequently used in patients at high risk of complications when they were contraindicated. There is a need to increase awareness of potential inappropriate prescribing and to monitor the quality of prescribing patterns in order to help physicians and policymakers to yield better clinical outcomes in T2DM.

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Clinical Value of Continuous Blood Purification in the Treatment of Severe Sepsis

10.47939/mh.v2i5.88 ◽

2021 ◽

Keyword(s):

Severe Sepsis ◽

Blood Purification ◽

Clinical Value ◽

Continuous Blood Purification

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MON-694 EDKA and MALA in the Setting of Severe Heart Failure and Acute Renal Failure, Due to SGLT2-i

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1689 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Jonathan Calvin Heckart ◽

Michael Shaw

Keyword(s):

Heart Failure ◽

Renal Failure ◽

Acute Renal Failure ◽

Lactic Acidosis ◽

Fluid Intake ◽

Severe Heart Failure ◽

Complete Recovery ◽

Unique Challenge ◽

Antihyperglycemic Therapy ◽

Increased Risk

Abstract Background: EDKA is a reported potential side effect of SGLT-2i that presents a unique challenge for diagnosis and management in the setting of HF and concurrent AKI. Literature encourages wide use of SGLT-2i’s, however this case demonstrates the need of proper evaluation before initiating therapy. Case: A 53 year old male with PMH of T2DM, Atrial fibrillation, HFrEF, presented to the Emergency Dept after a week of confusion, nausea, vomiting, and diarrhea. These symptoms were presumed due to gastroenteritis and our patient continued working on his farm in the summer heat. Following 3 days of intractable vomiting, he began to develop confusion, took his medications and presented to the ED. He was on metformin and had recently started empagliflozin following a heart failure exacerbation. Upon arrival the patient was noted to have a severe AKI with Cr of 15, hyperkalemia with potassium of 7.7, Anion gap of 45, bicarbonate of 4. Lactic acid was noted to be 7.7 and BHB was later noted to be 10.5 with a serum blood glucose of 155. Pt was determined to have Euglycemic Diabetic Ketoacidosis with an additional Metformin associated lactic acidosis. He was started on an insulin drip with a concurrent D20 infusion to minimize fluid intake. Dextrose was titrated up to maintain a goal BG of 150-180 while on a stable insulin rate of 5u/hour, while monitoring serum ketones to resolution of DKA. Due to excess fluid intake he required intubation and later, hemodialysis due to metformin associated lactic acidosis and acute renal failure. Following 3 days of dialysis he was able to successfully wean from vent and pressors, making a complete recovery. Conclusion: We present a patient with EDKA likely resulting from dehydration induced AKI compounded by SGLT2i induced diuresis. As he developed his kidney injury, metformin was able to build up to toxic levels inducing lactic acidosis. Treatment in this patient was based on the underlying physiology providing glucose to allow resolution of ketosis. Treatment is not well studied, but given the origin of the pathology should resemble a standard DKA protocol with glucose repletion. SGLT2i and metformin combinations have shown an increased risk of metabolic acidosis1 and lactic acidosis2. This case highlights a potential risk of the combination in the setting of renal insufficiency and tenuous fluid states. References: (1) Donnan, Katherine, and Lakshman Segar. “SGLT2 Inhibitors and Metformin: Dual Antihyperglycemic Therapy and the Risk of Metabolic Acidosis in Type 2 Diabetes.” European Journal of Pharmacology, U.S. National Library of Medicine, 5 Mar. 2019. (2) Schwetz V, Eisner F, Schilcher G, et al. Combined metformin-associated lactic acidosis and euglycemic ketoacidosis. Wien Klin Wochenschr. 2017;129(17-18):646–649. doi:10.1007/s00508-017-1251-6

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