الكويت (case report( Group A3 باطنة.pptx

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1. Insulin Overdose and Suicide Attempt with Renal Involvement in Type I Diabetic Patient

2. Prepared by : Boushra Al- Qubaia Roadah Naji Aisha Al- Maghrbi

3. Patient Demographics Age : 19 years old Gender : female   Occupation : Student  Resident : Sanaa   Special habits: - ve Date of admission : 13.3.2025

4. Chief Complaint Generlized body swelling 6 days P.D.A

5. History of Present Illness Patient known case of diabetic mellitus type1 for13 years on irregular ttt and follow up. The patient was in her usual state until 3weeks ago when she took a single high dose of insulin, the exact dosage and type of which are unknown then she disturbed level of conscious for few minutes then got better after gave her some juice,

6. after few hours she started to complain of hematuria sudden onset, stationary course, offensive odder, no reliving or aggravating factors, associated with flank pain 3weeks in duration, after one week she started to complain of periorbital edema then got generalized edema sudden onset, progressive course,

7. no reliving or aggravating factors, associated with dyspnea, PND, orthopnea, palpation, fatigue, headache, blurred of vision, epigastric pain, nausea. Regarding to DM ( NO increase or decrease amount of urine, urgency, dysuria, constipation, lose of sensation, numbness)

8. NO skin rash, photosensitivity, tinnitus, oral or genital ulcer, sore thought, but also has hair lose, oligomenorrhia , hypomenorrhia . ROS: irrelevant.

9. no similar attack, but she was admitted to the ICU 13 years ago when type one diabetes was discovered . no previous surgical operation no blood transfusion. No allergies. family history : Negative Past history:

10. Physical Examination

11. General examination: Patient looks ill, conscious, oriented to time, persons, and place, pale, no jaundice or cyanosis. There's generalizing edema pitting, painless, grade one and has brown pigmentation on upper back and chest about 10 x 20 cm.

12. Vital signs : BP : 170/ 100 mmHg pulse: 110 b/ min RR:21 c/min SPo : 98% Temp: 37.7

13. Abdominal examination: By inspection abdomen is distended with full flank, inverted umbilicus , midway ,no discharge. no scars or dilated veins. by palpation there's tenderness in epigastric, right hypochondria and flank area bilaterally, and no organomegally noted.

14. Cardiac examination: Audible heart sound S1 &S2 and no added sound. Defuse and heavy apex beat . Respiratory examination: Decreased air entry in left side ,vesicular breath ,no added sound, no scar ,no deformity or pigmentation. CNS : intact.

15. DOCTOR’S ADVICE

16. Initial ER Management: sending for routine investigations. Medications: - IV line normal saline 1000 cc !!!  - Emeset 4 mg IV stat - 10 unit insulin in drip - Foley's catheter insertion - Check RBC every 30 min

17. Admission Plan: - N/S 250 cc IV 1x3 - Heparin 2500 IU SC 1x2 - Ramipril 5 mg tab 1x1 - Pantoprazole 40 mg IV 1x1 - Forcef 1g IV AST 1x2 - Levofloxacin 500 mg inf 1x1 - Check RBS 1x4 - Check BP 1x4 - Input output chart - Soluble insulin according to sliding scale - Perfelgan 1g SOS and if temp. > 38

18. lab investigations : CBC,ESR,CRP, LFT, KFT, SE, RBS, cardiac enzymes, ANA, ECG, Echo, Chest X-ray)

19. Follow up : 2 nd day The patient’s symptoms have not improved CBC : Normal except Hb (10.2 g/dl), elevated lymphocyte(63 %) ESR: 32 mm/ hr CRP: 6.5mg/l Urine analysis: turbid, Albumen+, Hemoglobin++, RBCs(8-10), Pus cells(4-6), epithelial(++) KFT: normal except urea(72.98 mg/dl) Spot urine for albumin: (91.3 mg/dl) HbA1c: (11.5%)  

20. LFT: normal ECG : normal Cardiac enzyme : normal SE: normal ANA: negative Advice: Mextard insulin 30 IU A.M and 20 IU P.M Soluble insulin 4 unit 1x3 before meals Stop insulin according sliding scale C.O.T Requested investigation: (lipid profile, chest X.ray , Abd . US, Spot urine for protein).

21. Follow up : 3rd day The patient’s symptoms have not improved Lab Results: cholesterol(210mg/dl),Triglyceride(257mg/dl), LDL(134mg/dl),Risk factor(LDL/HDL)(3.3), Spot urine for protein(627mg/dl) Imagine:

22. Abdominal US within normal except bilateral renal small stones seen about 3mm size, cystitis, pelvic inflammatory process- mild amount free fluid in douglus pouch.

23. Advice: Amylodipin 5 mg 1x1 Lasix 40 mg tab 1x1 Paracetamol 500 cc C.O.T Requested investigation: ( H. pylori, ASO, TSH, RFT, Iron profile )

24. Follow up : 4th day The patient’s symptoms and sign are improving. Lab Results: (H. pylori(- Ve ), RFT(normal except S. urea(11.81mmol/dl), Iron profil (normal) Advice: - Stop IV fluid - Change Pantoprazole IV to oral - Vit . D 500 IU tab 1x1 - Neurobion tab 1x1 - Caldcidenk sachet - plasil 10 mg tab 1x1

25. Follow up : 5th day The patient’s symptoms and sign are improving. Patient was advised upon discharge to: - forcef 1g 1x2x3 - Levofloxacin 500 mg 1x1x5 - Amylodipin 5 mg tab 1x1 - Ramipril 5 mg tab 1x1 - Lasix 40 mg 1x1 - Pantoprasole 40 mg tab 1x1 - Vit.D 5000 IU tab 1x1 - CalciD - dec tab 1x1

26. DDx :

27. Effects of Insulin Overdose on Renal Function in Diabetic Patients

28. . Introduction: Administering insulin is essential for glycemic control in diabetic patients. However, an overdose can lead to severe complications, including adverse effects on renal function.

29. Pathophysiology Direct Renal Effects of Insulin: 1- Renal Hemodynamics: Insulin effects renal blood flow and (GFR). High insulin levels may disrupt these processes and impairing kidney function. 2- Electrolyte Imbalances: insulin overdose can cause imbalances like hypokalemia , affecting kidney function and metabolic stability.

30. Indirect Renal Effects via Hypoglycemia: Insulin overdose can cause hypoglycemia low kidney perfusion AKI Also hypoglycemia triggers the sympathetic system vasoconstriction high blood pressure Insulin Na reabsorption water retention edema These responses can strain the kidneys and exacerbate existing renal issues.

31. Indirect Renal Effects via Hypoglycemia: Insulin overdose can cause hypoglycemia low kidney perfusion AKI Also hypoglycemia triggers the sympathetic system vasoconstriction high blood pressure Insulin Na reabsorption water retention edema BP AKI

32. Insulin overdose can cause hypoglycemia muscle breakdown risk of rhabdomyolysis AKA These responses can strain the kidneys and exacerbate pre-existing diabetic nephropathy.

33. Diabetic nephropathy

34. Diabetic nephropathy Definition : Diabetic nephropathy (DN) is a chronic kidney disease caused by damage to the glomeruli due to prolonged hyperglycemia in diabetes mellitus. It is one of the leading causes of end-stage renal disease (ESRD).

35. Epidemiology Affects approximately 20–40% of diabetic patients. More common in type 1 diabetes but increasing in type 2 due to rising prevalence. Major cause of morbidity and mortality among diabetics.

36. Pathophysiology Hyperglycemia → glomerular hyperfiltration → mesangial expansion. Thickening of glomerular basement membrane (GBM). Podocyte injury → proteinuria. Progressive fibrosis → decline in glomerular filtration rate (GFR).

37. Clinical Features Microalbuminuria (30–300 mg/day). Progresses to macroalbuminuria (>300 mg/day). Hypertension. Edema (especially in later stages). Fatigue and signs of uremia in advanced stages.

38. Diagnosis Urine albumin-to-creatinine ratio (ACR). Serum creatinine and estimated GFR. Renal ultrasound (to exclude other causes). Kidney biopsy (only in atypical cases).

39. Stages of Diabetic Nephropathy Stage 1: Hyperfiltration (↑ GFR). Stage 2: Silent stage (normal GFR, histologic changes). Stage 3: Microalbuminuria. Stage 4: Macroalbuminuria and declining GFR. Stage 5: ESRD (requires dialysis or transplant).

40. Management Glycemic control (HbA1c < 7%). Blood pressure control (ACE inhibitors or ARBs). Protein restriction in advanced stages. Lipid control and lifestyle modification. Avoid nephrotoxic drugs.

41. Prevention Tight glycemic control from early stage. Regular screening for albuminuria. Use of renin-angiotensin system blockers. Lifestyle changes: diet, exercise, weight control.

42. Prognosis Progressive if untreated. Early detection and intervention can slow progression. Main cause of dialysis and kidney transplantation in diabetics.

43. References 1. American Diabetes Association. Standards of Medical Care in Diabetes—2024. 2. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD. 3. Brenner & Rector’s The Kidney, 11th Edition. 4. Mayo Clinic, Diabetic nephropathy overview. 5. UpToDate : Diabetic kidney disease.

44. Thank You