A Diabetic Mom Caught A Fever. This Is Why Her Kidneys Stopped Working. MC is a 49 year old woman, presenting to the
emergency room with confusion, abdominal pain, and respiratory distress. Her son, Andrew, tells the admitting nurse
at admission that she had vomited 4 times over the last hour. 5 days ago, MC started to develop a sore throat
after attending her son’s high school football game. Some of the other parents by her were coughing
and sneezing. She was concerned that she might have caught
the flu from them so she took massive doses of vitamin C. It didn’t seem to work because she quickly
started to get a fever. She was getting busy at work and couldnt afford
to be sick, so she bought three over the counter fever medicines, and took them together. She made sure to take only the recommended
dose for each one. Overall, MC wasn’t particularly healthy. She had type 2 diabetes which had been worsening
over the last few years, but still decently controlled by the medicine metformin. As a typical person with diabetes, she also
had high blood pressure and kidney disease, both of which were controlled by the medicine
enalapril, whose class derived from the venom of the Brazilian Pit Viper, as that venom
would, among other events, drop blood pressures, and in humans, we use it in a controlled fashion
as a medicine to alter some of our hormones to control blood pressure. At one point, it did cross her mind that she
may have been taking too many medicines for her fever, but the over-the-counter drugs
seemed to be working, so no problem. 4 days after taking all of her medicines, MC
went out for dinner and started to feel stomach pain. After passing some watery movements, she thought
that she had some kind of food poisoning so to remedy this, she took some antidiarrheal
medicine, drank some water, and didn’t eat or drink for the rest of the day, because
she simply wasn’t hungry or thirsty. Interestingly enough, she didn’t have to
use the bathroom for the next 24 hours. The next morning MC woke up in a pool of cold
sweat, dizzy and confused. She decided to try and work from home but
she couldn’t focus. Nothing she read made any sense. Her stomach would start cramping and she couldn’t
stop sweating. She could feel hear heart skipping. As her son Andrew came back from school in
the afternoon, he found his mother laying on the floor, huddled over, while clenching
her stomach. He calls 911 and she arrives to the emergency
room where we are now. Given this patient’s history of present
illness, it’s not entirely obvious as to what’s wrong, but there are a few clues. Most immediately, a blood test reveals that
she has profound acidemia, a major acid presence in blood. Acid [pH in this case] is a measure of hydrogen ions in your blood. This hydrogen is what makes vinegar and lemon
juice sour. Cells need this hydrogen to function, but
if there’s too much of it then the cells can become deformed and damaged. If the blood is just 5 times more acidic than
normal, then that can be incompatible with life. And in MC, her blood is more than 5 times
acidic than normal, which leads us to the first clue. Humans maintain acid balance quickly through
the lungs and the kidneys. This should make sense, because both those organs
indicate a net flow out of the body. You breathe air out, which has carbon dioxide,
which exists in your blood as carbonic acid, and your kidneys produce urine, which can
be 3 to 300 times more acidic than blood, but if MC hasn’t used the bathroom since
she took the antidiarrheal medicines yesterday, then it means that the acid has not left her body through
urine so then it’s trying to go out through her lungs, explaining why she’s in respiratory
distress at presentation, breathing quick, deep and labored. But if nothing has entered her body since
she didnt eat or drink for more than a day, then where is this acid coming from? Further analysis of blood samples finds that
MC is suffering from lactic acidosis. -Osis meaning illness caused by lactic acid,
which is a byproduct of your body’s metabolism, famously, and wrongly, known as the cause
of sore muscles during exercise. And MC hasn’t been exercising, so something
else must be causing her metabolism to go wrong and because diabetes is a disease centered
around sugar, which is the fuel used by cells to yield energy which is the definition of
metabolism, then this leads us to the next clue. Diabetes is a hormone disease. Insulin is that hormone. Insulin is made by the pancreas and it's released
into your blood after you eat. When you eat, sugars enter your blood from
your mouth and your small intestines. These sugars cant just diffuse across the
cell membrane, they have to actively be transported in, and insulin is the hormone that enables
that transportation. Only once that sugar is in the cell, can it
be converted to energy. In type 1 diabetes, patients’ pancreas is
dysfunctional, so they don’t make insulin, meaning that the sugar in their blood stays high
and it never gets into their cells. These cells begin to waste away and eventually
die off. And before the discovery of insulin, type
1 diabetes was a death sentence. But there’s also a type 2 diabetes where
the patient’s pancreas is functional, insulin is made and released, but the cells no longer
respond to that insulin. In response, the body believes it’s starving
because no sugar is going into the cells, so it commands that the muscles and the liver
which are both primary storage sites of sugar to release even more sugar into the blood. And that's sugar which will never enter the cell, because
those cells are resistant to insulin. So let’s go back to MC’s past medical
history. She has type 2 diabetes, so her body makes
some insulin, though less than normal, but her cells largely don’t respond to it. Given that shes presenting with lactic acidosis,
and that her body is producing this acid through her metabolism, then her diabetes must be
responsible for her condition. But we need to go further. Sugar is stored in both the muscle and liver
tissue, and in a type 2 diabetic, these tissues constantly leak out this sugar into the blood. We know she wasn't exercising, ruling out
the muscle, so then that leaves the source of her acidosis to be her liver. Because she doesn’t have a history of liver
disease, and we know that all oral medicines, which are the ones she took go from the stomach to the small intestines
then must pass through the liver first, then it means that the next clue is in her medication list. Metformin is the first line pharmacologic
treatment for type 2 diabetes. It works by decreasing the liver’s production and release
of sugar into the blood. That doesn’t give us much information on
MC’s acidosis. But metformin also works in the small intestines
by enhancing the conversion of sugar to a compound called lactate, so instead of sugar
getting stored into the liver, it’s lactic acid. This lactic acid is usually broken down by
the liver, and if MC doesn’t have prior liver dysfunction, then she should be breaking
down this lactic acid, right? Yes, but lets go back to how the body maintains
acid balance, which is really a more specific form of managing waste. The lungs are important because you can breathe
out carbon dioxide, which is a waste product of metabolizing sugar to energy. The gastrointestinal tract is important because
it can concentrate some acid in poop, but that process is slow. The liver is important because it breaks down
chemicals, drugs and wastes, by turning them more water soluble, meaning they dissolve
in water. And because all of the body's water is processed by
the kidneys, then it means that lactic acid broken down by the liver should be going to MC's
kidneys. But if she hasn't produced any urine for more
than a day, and her medical record notes she has kidney dysfunction due to her diabetes,
then it means that her acidemia and lactic acidosis must be because of her kidneys. Do you remember that blood pressure medicine,
enalapril, that MC was taking? Well, enalapril is supposed to protect the
kidneys in diabetes by vasodilating the efferent arteriole. This means that it relaxes the blood vessel that leads
out of the kidney, lowering the resistance of flow, and decreasing pressure. You want this in a diabetic because excess
blood sugar will complex with proteins and accumulate in the kidneys and this buildup
can damage the blood vessels. If MC’s kidneys have no problem letting
blood flow out of the kidney but she hasn’t produced urine for the last 24 hours, then
it means there’s been little to no flow in to her kidneys. The fever medicines that MC took were aspirin,
ibuprofen, and naproxen, are all drugs of the same class called nonsteroidal antiinflammatory
drugs. They relieve pain, and reduce fever, but they
also constrict the blood vessel leading in to the kidney. And because MC took all 3 together, while
taking enalapril, it means that there was limited flow in, and a lot of flow out of
her kidneys, "drying" them out, and allowing metformin, which isn’t metabolized by the
liver, to accumulate in the body, producing more lactic acid and making her blood 8 times
more acidic than normal. Her past medical history all point to this. The respiratory distress. The profuse sweating. The mental decline and vomiting. If this goes untreated, the proteins in her
body will quickly become denatured, and her enzymes will stop functioning as she becomes
consumed in an acid bath of her own blood. The accumulation of toxic waste is a recurring
physiologic theme when it comes to causes of death in humans. An alcoholic can have a cirrhosed liver, or
99% damaged and scarred. This is a time when ammonia which comes from
the breaking down of proteins in the small intestines isn’t processed by the liver
because it’s not functional. This ammonia begins to spill into the blood
and accumulate in the body, altering the metabolism of the brain causing a functional impairment
called hepatic encephalopathy. In the case of suffocation from drowning or
opioid overdose, the cessation of oxygen flow into the body causes hypoxemia, or a
low oxygen presence in blood. Carbon dioxide beings to build up in the blood,
manifesting as carbonic acid. This lack of oxygen in the brain can force
the brain cells to die, causing permanent brain damage. A genetic disorder called Cystic Fibrosis
mutates every single cell in the body and results in aberrant chloride transport in cells. This leads to abnormally thick mucus that
cannot be cleared easily. This mucus accumulation causes the lungs to chronically be infected, as there’s minimal flow out and in some cases it can cause pancreatic
enzymes to seldom be released outside the pancreas, enabling those enzymes to digest
part of the pancreas itself, resulting in malnutrition and eventual cystic fibrosis
related diabetes, which has characteristics of type 1 and type 2 together, as the pancreas’
function is severely diminished, decreasing its ability to produce insulin. And because the implication of a disease centered
around a hormone like diabetes is based on its presence, or the lack of response to its presence, the
mass balance concept of accumulation is a fundamental physiologic concept that describes
MC’s case. At this point, the easiest way to treat her
is to use the same chemistry that was used to identify her acidosis. If acidemia is a measure of excess hydrogen
in blood, then neutralizing it with a base like sodium bicarbonate, would react with
the hydrogen to produce water. She is aggressively hydrated so that her blood
pressure is temporarily higher, increasing flow through the constricted afferent arteriole
of the kidneys, forcing water through, and she is started on dialysis which filters the
blood and removes the wastes that functional kidneys would have caught. 48 hours after presenting to the emergency
room, MC’s metabolic abnormalities began to normalize. Blood pH began to rise back to normal levels,
and upon resolution of her confused and altered mental status, copious urination preceded
her hugging her son for the first time in days. Thank you to Audible for sponsoring this video,
of which I will donate part of the proceeds to the Shriner’s Hospitals for Children
and then, I will personally match that donation. Please check out Audible link in the description
below. There’s a great medical story I wanted to
share with you, that you can get for free. It’s called The Butchering Art by Dr. Lindsey
Fitzharris. I met her back on Halloween of 2017, and the
story is that of Dr Joseph Lister and his path towards revolutionizing surgery through
antiseptic technique, which virtually changed surgery in almost every aspect. The Audible version is narrated by Ralph Lister,
who is a relative of Joseph Lister. And the great thing about medicine, you can
still read Dr. Lister’s publications on Antiseptic Principle that were written in 1867 and published
in the British Medical Journal. If you don’t like it you can exchange for
a different book or cancel within the month. Audible dot com slash Chubbyemu or text Chubbyemu
to 500500. Thank you so much for watching. Take care of yourself. And be well.
