Diabetic Ketoacidosis and Hyperosmolar Nonketotic Syndrome

  • Horacio J. Adrogué


The term diabetes (a siphon, in Greek) was coined by Aretaeus the Cappadocian during the second century AD as a description of the polyuria that accompanies this disease. He graphically described the illness as “a melting down of the flesh and limbs into urine,” associated with an unquenchable thirst, nausea, vomiting, and rapid death (1). Even before Aretaeus, Egyptian physicians writing in the Papyrus Ebers described polyuria that, in retrospect, may have been the osmotic diuresis of diabetes mellitus. Thomas Willis (1621–1675), namesake of the Circle of Willis, noted the sweet taste of the urine and attributed the increasing incidence of diabetes in England to “good fellowship and gusling down chiefly of unalloyed wine.” Matthew Dobson, during the later half of the eighteenth century, published a case report of a young man with diabetes and performed experiments on the urine, finding both protein and sugar. He observed the patient’s serum and noted that it was also sweet and rather opaque. A prominent physician, Adolph Kussmaul, recognized that the hyperpnea of diabetic patients in coma was neither due to a primary lung disease nor associated with lack of oxygen; the respiratory pattern of these patients now bears his name. Several years later (1889,1890), Oskar Minkowsky induced diabetes mellitus in dogs by removal of the pancreas (2). During this century, our understanding of the pathogenesis of diabetes mellitus and, as a consequence, the management of the disease has grown substantially due to contributions by researchers studying the clinical and basic biochemical aspects of the illness.


Metabolic Acidosis Cerebral Edema Diabetic Ketoacidosis Volume Depletion Diabetic Coma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Major RH: Classic Description of Disease. Charles C. Thomas, Springfield, IL, pp 234–237, 1945.Google Scholar
  2. 2.
    Mering J, Minkowski O: Diabetes mellitus after extirpation of the pancreas. Arch F Exp Pathol Urol Pharmakol 375:26, 1889–1890.Google Scholar
  3. 3.
    Felig P: Diabetic ketoacidosis. N Engl J Med 290: 1360–1363, 1974.PubMedCrossRefGoogle Scholar
  4. 4.
    Kreisberg RA: Diabetic ketoacidosis: New concepts and trends in pathogenesis and treatment. Ann Intern Med 88: 681–695, 1978.PubMedCrossRefGoogle Scholar
  5. 5.
    Karam JH, Salber PR, Forsham PH: Pancreatic hormones and diabetes mellitus. In: FS Greenspan, PH Forsham, eds, Basic and Clinical Endocrinology. Lange Medical Publications, East Norwalk, pp 523–574, 1986.Google Scholar
  6. 6.
    Skillman TG: Diabetes mellitus. In: EL Mazzaferri, ed, Endocrinology. Medical Examination Publishing, New York, pp 595–665, 1986.Google Scholar
  7. 7.
    Adrogué HJ, Maliha G: Diabetic ketoacidosis. In: HJ Adrogué, ed, Acid—Base and Electrolyte Disorders. Contemporary Management in Critical Care, vol. 1. Churchill Livingstone, New York, pp 21–35, 1991.Google Scholar
  8. 8.
    Kreisberg RA: Diabetic ketoacidosis, acoholic ketosis, lactic acidosis, and hyporeninemic hypoaldosteronism. In: M Ellenberg, H Rifkin, eds, Diabetes Mellitus. Medical Examination Publishing, New York, pp 621–653, 1983.Google Scholar
  9. 9.
    Felts PW: Ketoacidosis. Med Clin North Am 67: 831–843, 1983.PubMedGoogle Scholar
  10. 10.
    Fleckman AM: Diabetic ketoacidosis. Endocinol Metab Clin North Am 22: 181–207, 1993.Google Scholar
  11. 11.
    Alberti KGMM: Diabetic acidosis, hyperosmolar coma, and lactic acidosis. In: KL Becker, ed, Principles and Practice of Endocrinology and Metabolism. J.B. Lippincott, Philadelphia, pp 1175–1187, 1990.Google Scholar
  12. 12.
    Davidson MB: Diabetic ketoacidosis and hyperosmolar nonketotic syndrome. In: MB Davidson, ed, Diabetes Mellitus, Diagnosis and Treatment. Churchill Livingstone, New York, pp 175–212, 1991.Google Scholar
  13. 13.
    Genuth SM: Diabetic ketoacidosis and hyperglycemic hyperosmolar coma. In: CW Bardin, ed, Current Therapy in Endocrinology and Metabolism. B.C. Decker, Philadelphia, pp 348–353, 1991.Google Scholar
  14. 14.
    Marshall SM, Walker M, Alberti KGMM: Diabetic ketoacidosis and hyperglycaemic non-ketotic coma. In: KGMM Alberti, RA DeFronzo, H Keen, et al., eds, International Textbook of Diabetes Mellitus. John Wiley, Chichester, pp 1151–1164, 1992.Google Scholar
  15. 15.
    Matz R: Uncontrolled diabetes mellitus: Diabetic ketoacidosis and hyperosmolar coma. In: M Bergman, ed, Principles of Diabetes Management. Medical Examination Publishing, New York, pp 109–121, 1987.Google Scholar
  16. 16.
    Adrogué HJ, Barrero J, Ryan JE, et al., Diabetic ketoacidosis: a practical approach. Hosp Pract 24: 83–112, 1989.Google Scholar
  17. 17.
    Fulop M, Rosenblatt A, Kreitzer SM, et al., Hyperosmolar nature of diabetic coma. Diabetes 24: 594–599, 1975.PubMedCrossRefGoogle Scholar
  18. 18.
    Adrogué HJ, Barrero J, Dolson GM: Diabetic ketoacidosis. In: WN Suki, SG Massry, eds, Therapy of Renal Diseases and Related Disorders, 2nd ed. Martinus Nijhoff Publishers, Boston, pp 193–206, 1991.CrossRefGoogle Scholar
  19. 19.
    Oster JR, Epstein M: Acid-base aspects of ketoacidosis. Am J Nephrol 4: 137–151, 1984.PubMedCrossRefGoogle Scholar
  20. 20.
    Keller U: Diabetic ketoacidosis: current views on pathogenesis and treatement. Diabetologia 29: 71–77, 1986.PubMedCrossRefGoogle Scholar
  21. 21.
    Adrogué HJ, Wilson H, Boyd AE, III, et al.: Plasma acid-base patterns in diabetic ketoacidosis. N Engl J Med 307: 1603–1610, 1982.PubMedCrossRefGoogle Scholar
  22. 22.
    Kleeman CR, Narins RG: Diabetic acidosis and coma. In: MH Maxwell, CR Kleeman, eds, Clinical Disorders of Fluid and Electrolyte Metabolism. McGraw-Hill, New York, pp 1339–1377, 1980.Google Scholar
  23. 23.
    Gamblin GT, Ashburn RW, Kemp DG, et al.: Diabetic ketoacidosis presenting with a normal anion gap. Am J Med 80: 758 760, 1986.Google Scholar
  24. 24.
    Adrogué HJ, Eknoyan G, Suki WN: Diabetic ketoacidosis: role of the kidney in the acid-base homeostasis reevaluated. Kidney Int 25: 591–598, 1984.PubMedCrossRefGoogle Scholar
  25. 25.
    Cronin JW, Kroop SF, Diamond J, et al.: Alkalemia in diabetic ketoacidosis. Am J Med 77:192–194, 1984.Google Scholar
  26. 26.
    Beigelman PM, Martin HE, Miller LV, et al.: Severe diabetic ketoacidosis. JAMA 210: 1082–1086, 1969.PubMedCrossRefGoogle Scholar
  27. 27.
    Taylor AL: Diabetic ketoacidosis. Postgrad Med 68: 161–173, 1980.PubMedGoogle Scholar
  28. 28.
    Vignati L, Asmal AC, Black WL, et al.: Coma in diabetes. In: Joslin’s Diabetes Mellitus. Lea and Febiger, Philadelphia, pp 526–552, 1985.Google Scholar
  29. 29.
    Davidson MB: Diabetic ketoacidosis and hyperosmolar nonketotic coma. In: MB Davidson, ed, Diabetes Mellitus: Diagnosis and Treatment. Wiley Medical, New York, pp 193241, 1981.Google Scholar
  30. 30.
    Kitabchi AE, Matteri R, Murphy MB: Optimal insulin deliv ery in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNC). Diabetes Care 5 (Suppl 1): 78–87, 1982.PubMedGoogle Scholar
  31. 31.
    Beigelman PM: Severe diabetic ketoacidosis. In: PM Beigelman, D Kumar, eds, Diabetes Mellitus for the Houseofficer. Williams & Wilkins, Baltimore, pp 23–36, 1986.Google Scholar
  32. 32.
    Ellemann K, Soerensen JN, Pedersen L, et al.: Epidemiology and treatment of diabetic ketoacidosis in a community population. Diabetes Care 7: 528–532, 1984.PubMedCrossRefGoogle Scholar
  33. 33.
    Johnson DG: Diabetic ketoacidosis. In: R Bressler, DG Johhnson, eds, Management of Diabetes Mellitus. John Wright PSG, Boston, pp 153–174, 1982.Google Scholar
  34. 34.
    Kitabchi AE, Young R, Sacks H, et al. Diabetic ketoacidosis. Reappraisal of therapeutic approach. Annu Rev Med 30: 339357, 1979.Google Scholar
  35. 35.
    Kozak GP, Rolla AR: Diabetic comas. In: GP Kozak, ed, Clinical Diabetes Mellitus. WB Saunders, Philadelphia, pp 109–145, 1982.Google Scholar
  36. 36.
    Pedersen O, Beck-Nielsen H: Insulin resistance and insulin-dependent diabetes mellitus. Diabetes Care 10: 516–523, 1987.PubMedGoogle Scholar
  37. 37.
    Lever E, Jaspan JB: Sodium bicarbonate therapy in severe diabetic ketoacidosis. Am J Med 75: 263–268, 1983.PubMedCrossRefGoogle Scholar
  38. 38.
    Morris LR, Murphy MB, Kitabchi AE: Bicarbonate therapy in severe diabetic ketoacidosos. Ann Intern Med 105: 836840, 1986.Google Scholar
  39. 39.
    Levine SN, Loewenstein JE: Treatment of diabetic ketoacidosis. Arch Intern Med 141: 713–715, 1991.CrossRefGoogle Scholar
  40. 40.
    Narins RG, Arieff AI: Alkali therapy of metabolic acidosis due to organic acids. AKF Nephrol Lett 2: 13–22, 1985.Google Scholar
  41. 41.
    Adrogué Hi, Chap Z, Okuda Y, et al.: Acidosis-induced glucose intolerance is not prevented by adrenergic blockade. Am J Physiol 255: E812 - E823, 1988.PubMedGoogle Scholar
  42. 42.
    Assal JP, Aoki TT, Manzano FM, et al.: Metabolic effects of sodium bicarbonate in the management of diabetic ketoacidosis. Diabetes 23: 405–411, 1974.PubMedGoogle Scholar
  43. 43.
    Bureau MA, Begin R, Berthiaume Y, et al.: Cerebral hypoxia from bicarbonate infusion in diabetic acidosis. J Pediatr 96: 968–973, 1980.PubMedCrossRefGoogle Scholar
  44. 44.
    Okuda Y, Adrogué HJ, Field JB, et al.: Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis. J Clin Endocrinol Metab,in press.Google Scholar
  45. 45.
    Madias NE, Adrogué HJ: Influence of chronic metabolic acid-base disorders on the acute CO2 titration curve. J Appl Physiol 55: 1187–1195, 1983.PubMedGoogle Scholar
  46. 46.
    Madias NE, Bossert WH, Adrogué HJ: Ventilatory response to chronic metabolic acidosis and alkalosis in the dog. J Appl Physiol 56: 1640–1646, 1984.PubMedGoogle Scholar
  47. 47.
    Adrogué HJ, Brensilver J, Cohen JJ, et al.: Influence of steady-state alterations in acid-base equilibrium on the fate of administered bicarbonate in the dog. J Clin Invest 71: 867883, 1983.Google Scholar
  48. 48.
    Adrogué HJ, Wesson DE: Blackwell’s Basics of Medicine. Volume 1: Acid-Base. Blackwell Scientific Publication, Boston, 1994.Google Scholar
  49. 49.
    Roscoe JM, Halperin ML, Rolleston FS, et al.: Hyperglycemia-induced hyponatremia: Metabolic considerations in calculation of serum sodium depression. Can Med Assoc J 112: 452–453, 1975.PubMedGoogle Scholar
  50. 50.
    Trever RW, Cluff LE: The problem of increasing azotemia during management of diabetic acidosis. Am J Med 24: 368375, 1958.Google Scholar
  51. 51.
    Linton AL, Kennedy AC: Diabetic ketosis complicated by acute renal failure. Postgrad Med J 39: 364–366, 1963.PubMedCrossRefGoogle Scholar
  52. 52.
    Adrogué HJ, Barrero J, Eknoyan G: Salutary effects of modest fluid replacement in the treatment of adults with diabetic ketoacidosis. JAMA 262: 2108–2113, 1989.PubMedCrossRefGoogle Scholar
  53. 53.
    Kandel G, Aberman A: Selected developments in the understanding of diabetic ketoacidosis. Can Med Assoc J 128: 39 2397, 1983.Google Scholar
  54. 54.
    Brown RH, Rossini AA, Callaway CW, et al.: Caveat on fluid replacement in hyperglycemic, hyperosmolar, nonketotic coma. Diabetes Care 1: 305–307, 1978.PubMedGoogle Scholar
  55. 55.
    Fulop M: The treatment of severely uncontrolled diabetes mellitus. Adv Intern Med 29: 327–356, 1984.PubMedGoogle Scholar
  56. 56.
    Khardori R, Soler NG: Hyperosmolar hyperglycemic nonketotic snydrome. Am J Med 77: 899–904, 1984.PubMedCrossRefGoogle Scholar
  57. 57.
    Gundersen HJG, Christensen NJ: Intravenous insulin causing loss of intravascular water and albumin and increased adrenergic nervous activity in diabetics. Diabetes 26: 551–557, 1977.PubMedGoogle Scholar
  58. 58.
    Foster DW, McGarry JD: The metabolic derangements and treatment of diabetic ketoacidosis. N Engl J Med 309: 159169, 1983.Google Scholar
  59. 59.
    Nattrass M, Hale PJ: Clinical aspects of diabetes ketoacidosis. In: M Nattras, W Santiago, eds, Churchill Livingstone, Edinburg, pp 231–238, 1984.Google Scholar
  60. 60.
    Adrogué HJ, Madias NE: Changes in plasma potassium concentration during acute acid-base disturbances. Am J Med 71: 456–467, 1981.PubMedCrossRefGoogle Scholar
  61. 61.
    Adrogué HJ, Lederer ED, Suki WN, et al.: Determinants of plasma potassium levels in diabetic ketoacidosis. Medicine 65: 163–172, 1986.PubMedGoogle Scholar
  62. 62.
    Adrogué HJ, Chap Z, Ishida T, et al.: Role of the endocrine pancreas in the kalemic response to acute metabolic acidosis in concious dogs. J Clin Invest 75: 798–808, 1985.PubMedCrossRefGoogle Scholar
  63. 63.
    Goldfarb S, Cox M, Singer I, et al.: Acute hyperkalemia induced by hyperglycemia: hormonal mechanisms. Ann Intern Med 84: 426–432, 1976.PubMedCrossRefGoogle Scholar
  64. 64.
    Adrogué HJ: Mechanisms of transcellular potassium shifts in acid-base disorders. In: M Hatano, ed, Proc. Xlth International Congress of Nephrology. Springer-Verlag Tokyo, pp 252–261, 1991.Google Scholar
  65. 65.
    Adrogué HJ, Wesson DE: Blackwell’s Basic of Medicine. Volume 2: Potassium. Blackwell Scientific Publication, Boston, 1994.Google Scholar
  66. 66.
    Fraley DS, Adler S: Isohydric regulation of plasma potassium by bicarbonate in the rat. Kidney Int 9: 333–343, 1976.PubMedCrossRefGoogle Scholar
  67. 67.
    Fraley DS, Adler S: Correction of hyperkalemia by bicarbonate despite constant blood pH. Kidney Int 12: 354–360, 1977.PubMedCrossRefGoogle Scholar
  68. 68.
    Makoff DL, DaSliva JA, Rosenbaum BJ, et al.: Hypertonic expansion: acid-base and electrolyte changes. Am J Physiol 218: 1201–1207, 1970.PubMedGoogle Scholar
  69. 69.
    Massara F, Martelli S, Cagliero E, et al.: Influence of glucagon on plasma levels of potassium in man. Diabetologia 19: 414–417, 1980.PubMedCrossRefGoogle Scholar
  70. 70.
    Silva P, Spokes K: Sympathetic system in potassium homeostasis. Am J Physiol 241: F151 - F155, 1981.PubMedGoogle Scholar
  71. 71.
    Cox M, Sterns RH, Singer I: The defense against hyperkalemia: the roles of insulin and aldosterone. N Engl J Med 299: 525–532, 1978.PubMedCrossRefGoogle Scholar
  72. 72.
    DeFronzo RA, Sherwin RS, Dillingham M, et al.: Influence of basal insulin and glucagon secretion on potassium and sodium metabolism. J Clin Invest 61: 472–479, 1978.PubMedCrossRefGoogle Scholar
  73. 73.
    Clausen T, Kohn PG: The effect of insulin on the transport of sodium and potassium in rat soleus muscle. J Physiol (Lond) 265: 18–42, 1977.Google Scholar
  74. 74.
    Moore RD, Rabovsky JL: Mechanism of insulin action on resting membrane potential of frog skeletal muscle. Am J Physiol 236: C249 - C254, 1979.PubMedGoogle Scholar
  75. 75.
    Kebler R, McDonald FD, Cadnapaphomchai P: Dynamic changes in serum phosphorus levels in diabetic ketoacidosis. Am J Med 79: 571–576, 1985.PubMedCrossRefGoogle Scholar
  76. 76.
    Fisher JN, Shahshahani MN, Kitabchi AE: Diabetic ketoacidosis: low-dose insulin therapy by various routes. N Engl J Med 297: 238–241, 1977.PubMedCrossRefGoogle Scholar
  77. 77.
    Pfeifer MA, Samols E, Wolter CF, et al.: Low-dose versus high-dose insulin therapy for diabetic ketoacidosis. South Med J 72: 149–154, 1979.PubMedCrossRefGoogle Scholar
  78. 78.
    Carroll P, Matz R: Uncontrolled diabetes mellitus in adults: experience in treating diabetic ketoacidosis and hyperosmolar nonketotic coma with low-dose insulin and a uniform treatment regimen. Diabetes Care 6: 579–585, 1983.PubMedCrossRefGoogle Scholar
  79. 79.
    Clerbaux T, Reynaert M, Willems E, Frans A: Effect of phosphate on oxygen-hemoglobin affinity, diphosphoglycerate and blood gases during recovery from diabetic ketoacidosis. Intensive Care Med 15: 495–498, 1989.PubMedCrossRefGoogle Scholar
  80. 80.
    Clements RS, Morrison AD, Blumenthal SA, et al.: Increased cerebrospinal-fluid pressure during treatment of diabetic ketosis. Lancet 2: 671–675, 1971.PubMedCrossRefGoogle Scholar
  81. 81.
    Young E, Bradley RF: Cerebral edema with irreversible coma in severe diabetic ketoacidosis. N Engl J Med 276: 665669, 1967.Google Scholar
  82. 82.
    Arieff AI, Kleeman CR: Studies on mechanisms of cerebral edema in diabetic comas. J Clin Invest 52: 571–583, 1973.PubMedCrossRefGoogle Scholar
  83. 83.
    Arieff AI, Kleeman CR: Cerebral edema in diabetic comas. II. Effects of hyperosmolality, hyperglycemia and insulin in diabetic rabbits. J Clin Endocrinol Metab 38: 1057–1067, 1974.PubMedCrossRefGoogle Scholar
  84. 84.
    Guisado R, Arieff AI: Neurologic manifestations of diabetic comas: correlation with biochemical alterations in the brain. Metabolism 24: 665–679, 1975.PubMedCrossRefGoogle Scholar
  85. 85.
    Winegrad AI, Kern EFO, Simmons DA: Cerebral edema in diabetic ketoacidosis. N Engl J Med 312: 1184–1185, 1985.PubMedCrossRefGoogle Scholar
  86. 86.
    Ohman JL, Marliss EB, Aoki TT, et al.: The cerebrospinal fluid in diabetic ketoacidosis. N Engl J Med 284: 283–290, 1971.PubMedCrossRefGoogle Scholar
  87. 87.
    Fein IA, Rackow EC, Sprung CL, et al.: Relation of colloid osmotic pressure to arterial hypoxemia and cerebral edema during crystalloid volume loading of patients with diabetic ketoacidosis. Ann Intern Med 96: 570–575, 1982.PubMedCrossRefGoogle Scholar
  88. 88.
    Krane EJ, Rockoff MA, Wallman JK, et al.: Subclinical brain swelling in children during treatment of diabetic ketoacidosis. N Engl J Med 312: 1147–1151, 1985.PubMedCrossRefGoogle Scholar
  89. 89.
    Maccario M, Messis CP: Cerebral edema complicating treated non-ketotic hyperglycemia. Lancet 2: 352–353, 1969.PubMedCrossRefGoogle Scholar
  90. 90.
    Beigelman PM: Severe diabetic ketoacidosis (diabetic coma). Diabetes 20: 490–500, 1971.PubMedGoogle Scholar
  91. 91.
    Halmos PB, Nelson JK, Lowry RD: Hyperosmolar nonketoacidotic coma in diabetes. Lancet 2: 675–679, 1966.CrossRefGoogle Scholar
  92. 92.
    Keller RJ, Wolfsdorf JI: Isolated growth hormone deficiency after cerebral edema complicating diabetic ketoacidosis. N Engl J Med 316: 857–859, 1987.PubMedCrossRefGoogle Scholar
  93. 93.
    Matz R: Coma in the nonketotic diabetic. In: M Ellenberg, H Rifkin, eds, Diabetes Mellitus Medical Examination Publishing, New York, pp 655–666, 1983.Google Scholar
  94. 94.
    Adrogué HJ: Glucose homeostasis and the kidney. Kidney Int 42: 1266–1282, 1992.PubMedCrossRefGoogle Scholar
  95. 95.
    Gerich JE, Martin MM, Recant L: Clinical and metabolic characteristics of hyperosmolar nonketotic coma. Diabetes 20: 228–238, 1971.PubMedGoogle Scholar
  96. 96.
    Khardori R, Soler NG: Hyperosmolar hyperglycemic nonketotic syndrome. Am J Med 77: 899–904, 1984.PubMedCrossRefGoogle Scholar
  97. 97.
    Danowski TS, Nabarro JDN: Hyperosmolar and other types of nonketoacidotic coma in diabetes. Diabetes 14: 162–165, 1965.PubMedGoogle Scholar
  98. 98.
    Jackson WPU, Forman R: Hyperosmolar nonketotic diabetic coma. Diabetes 15: 714–721, 1966.PubMedGoogle Scholar
  99. 99.
    Johnson RD, Conn JW, Dykman CJ, et al.: Mechanisms and management of hyperosmolar coma without ketoacidosis in the diabetic. Diabetes 18: 111–116, 1969.PubMedGoogle Scholar
  100. 100.
    Arieff AI, Carroll HJ: Nonketotic hyperosmolar coma with hyperglycemia: clinical features, pathophysiology, renal func tion, acid-base balance, plasma-cerebrospinal fluid equilibria and the effects of therapy in 37 cases. Medicine 51: 73–94, 1972.PubMedCrossRefGoogle Scholar
  101. 101.
    Adrogué HJ, Wesson DE: Blackwell’s Basics of Medicine. 107. Volume 3: Salt & Water. Blackwell Scientific Publication, Boston, 1994.Google Scholar
  102. 102.
    Schade DS, Eaton RP: Dose response to insulin in man: differential effects on glucose and ketone body regulation. J Clin Endocrinol Metab 44: 1038–1053, 1977.PubMedCrossRefGoogle Scholar
  103. 103.
    Joffe BI, Goldberg RB, Krut LH, et al.: Pathogenesis of nonketotic hyperosmolar diabetic coma. Lancet i: 1069–1071, 1975.Google Scholar
  104. 104.
    Whittaker J, Cuthbert C, Hammond VA, et al.: The effects of metabolic acidosis in vivo on insulin binding to isolated rat adipocytes. Metabolism 31: 553–557, 1982.PubMedCrossRefGoogle Scholar
  105. 105.
    Lindsey CA, Faloona GR, Unger RH: Plasma glucagon in nonketotic hyperosmolar coma. JAMA 229: 1171–1173, 1974.CrossRefGoogle Scholar
  106. 106.
    Gerich J, Panhaus JC, Gutman RA, et al.: Effect of dehydration and hyperosmolarity on glucose free fatty acid and ketone body metabolism in the rat. Diabetes 22: 264–271, 1973.PubMedGoogle Scholar
  107. 107.
    Rosenthal NR, Barrett EJ: An assessment of insulin action in hyperosmolar hyperglycemic nonketotic diabetic patients. J Clin Endocrinol Metab 60: 607–612, 1985.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 1998

Authors and Affiliations

  • Horacio J. Adrogué
    • 1
  1. 1.Renal Section Department of Veterans Affairs Medical CenterBaylor College of MedicineHoustonUSA

Personalised recommendations