00:04A Dad Didn’t Brush His Teeth for 40 Days.
This Is What Happened To His Kidneys.
00:10CJ is a 46 year old man, presenting to the
emergency room with excessive thirst, abdominal
00:17discomfort, and shortness of breath. He tells
the admitting nurse that he had lost 15 pounds
00:23over the last 2 weeks and had developed a
pounding toothache.
00:26You see, CJ was a dad who lost everything.
Earlier in his life, he was a successful engineer,
00:32with a happy family.
00:33Five years ago, on his 41st birthday, CJ lost
his 5 year old son in a sudden freak accident.
00:40He returned to work from bereavement leave,
only to find he was laid off. His wife, unable
00:45to cope with tragedy, left him before year’s
end.
00:49Bankrupt and unable to find new work, CJ was
forced in to government housing to a poor
00:54part of town. He found comfort and affordability
in certain foods and gained over 250 pounds (114kg)
01:02About 2 months ago, CJ’s mother, his last
sense of hope in family, passed away. In his
01:08sadness, he laid in bed all day, only getting
up to go to the convenience store to eat.
01:13He no longer cared for his own personal hygiene—
no longer brushed his teeth, no longer bathed.
01:18Over the next few weeks, he noticed something
wrong when he had an unquenchable thirst.
01:23Because juice is fruit, it must be healthy,
so drink more of it, he thought.
01:27One day, he drank 2 gallons juice and urinated
every 15 minutes. Just a lot of extra liquid, he thought.
01:35On the surface, CJ didn’t appear to be well.
He had glucosuria, or sugar in his urine.
01:41This was combined with his polydipsia, his
unquenchable thirst, and polyuria, his frequent
01:46urination. His face was turgid- swollen and
bloated. Evaluation of his oral cavity found
01:53an infected tooth, which inflamed his oral
mucosa and formed multiple pustules along
01:58his gums, all because he no longer found it
necessary to brush his teeth.
02:04A blood test reveals CJ’s blood glucose
level is 800 mg / dL, more than 10 times that
02:12In the emergency room, CJ becomes more lethargic.
His toothache was pounding. His blood pressure
02:17was dropping, and in the wait for medical
care, he finally collapses into coma.
02:23Given this past history, there’s several
clues as to what’s going on. Most immediately,
02:28CJ is suffering from hyperglycemic crisis.
Hyper meaning high. Glyce referring to glucose,
02:36or sugar, the primary source of energy for
cells, and emia meaning presence in blood.
02:41High glucose presence in blood and crisis
meaning there was an underlying cascade of
02:45events that brought about CJ’s metabolic
derangement, which leads us to the first clue.
02:51Because he was urinating every 15 minutes,
there was a substantial net flow of water
02:55out of his body. His urine has a lesser concentration
of sugar in it compared to the juice, which
03:01means that glucose is accumulating and concentrating
in his blood. We can prove this
03:07Because CJ weighed over 400 pounds at admission,
his estimated blood volume was about 9 liters.
03:13Given his blood glucose level of 800 mg / dL,
there are 72 grams, almost a one fifth pound
03:20of sugar, floating around in the blood. The
average amount for a healthy man weighing
03:25around 175 pounds (79.4kg) is 4 grams, 18 times less than CJ.
03:31Because CJ drank 2 gallons (7.57 L) of juice which amounted to 850 grams of sugar, and 72 are
03:37present in his blood, then where are the other
700 grams?
03:42Well, there’s a bit of basic human physiology
to be known here. When you eat, food goes
03:47into your stomach, then to the small intestines,
where fats, proteins and sugars, absorb through
03:53the liver, then are delivered to the body
through the blood. Glucose enters cells because
03:58the body releases a hormone named insulin
into circulation in response to food, shifting
04:04sugar into muscle, liver, and fat tissue for
storage.
04:08The problem with CJ is that both his diet
and his class 3 obesity, defined by his body
04:13mass index, allowed for massive disturbances
in high blood glucose levels, based on his
04:18choice and amount of foods. This caused an
overabundance of insulin to be in his blood constantly.
04:24Because cells don’t want this
continuous influx of glucose, they downregulate,
04:29or decrease the number of insulin receptors,
meaning they won’t accept as much sugar
04:33from the blood, leaving it floating around
as they become increasingly insulin resistant.
04:38Over the last 4 years, CJ, through his diet
of bountiful sugary and fatty foods, saturated
04:45his tissues with glucose and his body converted
those stores to fat. Unable to handle the
04:49overabundance of sugar, the body left it in
the blood to accumulate, where it inevitably
04:54overloaded the kidneys and began to spill
into the urine explaining CJ’s glucosuria.
04:59This is the chronic, or long-term, physiologic
consequence of CJ’s gross hyperglycemia,
05:05but there is also a life-threatnening chemical
consequence as well.
05:09CJ is in hyperosmolar hyperglycemic state.
Hyperosmolar, describing the chemistry responsible
05:16for what’s happening.
05:18The interesting thing about glucose is that
it creates an osmotic gradient. Which means
05:22wherever it is, water will flow towards it.
05:25In this small science experiment, I fill an
outside pool with sugar water. I submerge
05:30a tube filled with distilled, sugar free,
water, and you’ll see that water leaves
05:34the tube, that water flows towards the sugar.
05:38So lets go back to the name of CJ’s problem,
hyperosmolar hyperglycemic state. Because
05:43there’s a large glucose presence in blood,
sugar is drawing water out of his cells, exerting
05:49a hyperosmolar effect. Because his cells are
losing water, his body thinks he is dehydrated
05:55and release signals to his brain to alert
him of thirst, explaining his polydipsia.
06:01Because water is getting drawn into his intravascular
space, it increases the flow of water to the
06:06kidneys, causing them to filter more urine
explaining his polyuria.
06:10The hyperglycemia begins to draw water out
of his brain, dehydrating it, causing his
06:15neurological deficits, resulting in coma.
As his cells begin to dry out and he persists
06:21in excessive urination, his body becomes massively
dehydrated, decreasing perfusion to the already
06:27dried out kidneys, and causing acute kidney
injury. With the failure of kidneys, what
06:33should be CJ’s urine is now floating around
in his blood, rotting his bones through an
06:39imbalance of calcium and phosphate, altering
his brain chemicals through excess nitrogen,
06:44and disrupting the electrophysiology of the
heart through potassium. All because his body
06:50could no longer handle glucose.
06:53At this point, it is impossible to directly
remove the sugar from his blood. Even if we
06:59drained CJ’s body and transfused in fresh,
euglycemic blood, it too would become hyperglycemic
07:06to the point of crisis because the pathogenesis
of hyperosmolar hyperglycemic state is metabolic
07:12in nature. All of this precipitated by CJ’s
abscessed tooth.
07:19Because CJ hadn’t brushed his teeth for
40 days, his tooth became inflamed and infected.
07:24This infection seeped into his gums and began
to spill into his systemic circulation, and
07:29spread throughout his body, causing septicemia.
A bacteria presence in blood. This forced
07:35his immune system to activate, and caused
adrenaline to release
07:39in response to the physiologic stress.
07:42Because adrenaline is usually released when
you get scared or excited, it forces the liver
07:46and muscles, sites of storage for glucose,
to quickly release sugar into the blood. This
07:51makes sense because to fuel a fight or flight
response, you need sugar in blood for cells
07:57to generate mechanical energy. But its
release is inappropriate in CJ meaning his
08:02hyperglycemia was not only onset by the juice
he drank and his overall diet, but was amplified
08:07by his own body through physiologic stress
induced by poor oral hygiene. If this continues
08:14untreated, the electrolyte abnormalities onset
by renal failure through dehydration will
08:18cause cardiac arrhythmias and lead to sudden
death.
08:22The notion of metabolic derangement arising
from hyperglycemic crisis was observed thousands
08:28of years ago. In 1500 BC, ancient Egyptian
physicians wrote about a "too great emptying
08:35of the urine" that attracted ants. It was later
found that sugar was responsible for attracting
08:41the insects. Ancient Chinese medical texts
describe sugar urine disease, who’s pronunciation
08:48tang niao bing preserved into Japanese and
Korean. We know this today to be diabetes
08:54and this hyperglycemic crisis alone is sufficient
to diagnose CJ with type 2 diabetes, the disorder
09:01where the body does create insulin but does
not respond to it. Contrast with type 1 diabetes
09:07where the body doesn’t create insulin at
all.
09:10The notion of diabetic coma was first described
in western literature in 1828 by German physician
09:16August von Stosch who described severe polydipsia,
polyuria and glucosuria followed by decline
09:23in mental status leading to death.
09:25In the early 1900s, a diabetes diagnosis was
a death sentence. Without insulin patients
09:31would inevitably suffer hyperglycemia from
eating, causing dehydration, kidney injury,
09:36and coma, leading to death. It was only in
1921 when Canadian physician Frederick Banting
09:42and group extracted insulin from cows that
diabetes became a chronic treatable illness.
09:47It wasn’t until 1957 when humans finally
understood that the pathogenesis and etiology
09:52of coma and kidney injury in hyperglycemic
hyperosmolar state were due to extracellular
09:58hypertonicity and cellular dehydration arising
from underlying metabolic derangement accompanied
10:04with a major precipitating factor.
10:07For CJ, we treat his condition first by treating
his infection with antibiotics and in his
10:13case, the abscessed tooth was removed. Because
his blood was hyperosmolar due to glucose,
10:19we dilute his blood by infusing water into
his veins. Rehydration efforts will amount
10:24to as much as 20 liters given over 48 hours.
This will mitigate his dehydration and reduce
10:30the plasma osmolality that was onset by hyperglycemia
and begin to perfuse the kidneys, delivering
10:36oxygen to the tissue and alleviating acute
injury, allowing them to filter urine and
10:41remove wastes, while restoring water back
into the cells.
10:45With the physiologic stress removed on treatment
of his tooth, some insulin sensitivity will
10:51be restored and administering insulin intravenously
will allow more water to shift back into the
10:57cells, as well as replete potassium, an
electrolyte which was forced out of the cell
11:01during hyperglycemic crisis and excreted in
large quantities during polyuria.
11:07Today, we have sophisticated therapies and
techniques to treat diabetes. We have drugs
11:12that sensitize cells to insulin. Before 1977,
insulin that was originally derived from grinding
11:19pig and cow pancreas, would inevitably cause
allergic reactions after long term use. After
11:251980, we have genetically engineered E. coli
bacteria with recombinant human DNA, enabling
11:32them to produce human insulin in unadulterated
form. This paved the way for short and long
11:38acting insulin analogs to alleviate acute
and chronic aberrations in glycemic levels
11:43and helps maintain glucose control in the
elderly, where hypoglycemia onset from incorrect
11:49insulin doses will cause dizziness and loss
of consciousness leading to falls, shattering
11:55bones and hips, leading to increased mortality
in the elderly.
11:59Despite all of these techniques, tragedies
from underlying metabolic derangements will
12:04still happen from more factors than anyone
can image. Whether it be a gap or dislocation
12:10in medical care, a disruptive culture, or
simply a decline in lifestyle for various
12:15reasons, the causes are not simple. The data
today shows, as metabolisms slow when one
12:21begins to age, high body fat percentage bordering
on obesity, a decreased volume of total body
12:28water and atrophy of skeletal muscle, is almost
inevitable for a majority of people as they
12:34enter into elderhood. But that doesn’t mean
to ignore your health when you are young either.
12:40With continued monitoring in the ICU, counseling
and social support to bring CJ back from the
12:46brink, and a new hope to regain status in
his life once again
12:50CJ was able to make a full recovery.
12:55Thank you so much for watching. Take care
of yourself. And Be well.
