、
忙裡偷閒看了美劇《Hannibal》，S1E2中的人體蘑菇園令人嘆為觀止。種植方式是將還有生命體徵但是昏迷的人給予機械通氣（mechanical ventilation）和靜脈營養（intravenous feeding），逼格高一點是 （parenteral nutrition)，液體是葡萄糖（dextrose 直接叫glucose也行 ），人就成了蘑菇的培養基。
【溫馨提示】
膽小者勿看下圖
好端端的活人怎樣才會神不知鬼不覺的被搞昏？屍檢顯示受害者死於腎衰竭（acute renal failure), 結合前面提到的葡萄糖，於是就有了受害者都是糖尿病患者因酮症酸中毒繼發腎衰竭死亡的猜測。
問題來了，對於DKA（diabetic ketoacidosis)患者，最常見的死因是什麼？高滲性脫水+酸中毒+低鉀血症引發很多器官衰竭，最致命的是腦損傷，這也是教科書的經典解釋。那麼DKA會不會引發腎衰竭，繼而致命呢？
最致命的還是脫水
終於在BMJ上找到一篇小文章，文中收集的DKA患者發生急性腎衰的比例很低（1956-1992年該院只有14名DKA+繼發ARF），而另一篇case report 也報導了類似案例，並提出了DKA導致ARF的一些猜想：低血容量（hypovolemia),低血壓（hypotension),低磷血症，橫紋肌溶解，溶血還有繼發的DPG改變從而影響氧解離曲線。
」The etiology of ARF associated with DKA is probably multifactorial, most likely due to hypovolemia and hypotension. Prolonged profound ketoacidosis and insulin infusions can lead to severe hypophosphatemia, mainly as a result of intracellular phosphate shifting. In addition, urinary phosphate excretion is initially increased in response to an acidemia-induced inhibition of phosphate proximal tubular reabsorption.
Consequently, prolonged hypophosphatemia may lead to cardiomyopathy and rhabdomyolysis secondary to decreased intracellular concentration of ATP and 2,3 diphosphoglycerate (DPG). Hypophosphatemia also contributes to the metabolic acidosis, which cannot be compensated by the renal production of ammonia due to lower urinary excretion of phosphate in the course of DKA. Hypophosphatemia-induced decrease in DPG may also affect the oxygen dissociation curve which results in impaired oxygen delivery and eventually respiratory failure. In addition, haemolytic anemia may occur from hypophosphatemia-induced rigidity of the red cell membrane.「（太長了就直接看上面的結論）
本文的AKI可以用哪些圖中的經典機制來解釋？
再回到我們的案子，兇手是個藥劑師，偷換了患者的胰島素導致患者昏迷，按照隨機抽樣的原則，這批患者死於腦損傷的可能性應該更大一些，當然，也可能他們都有 pre-existing nephropathy,也算是自圓其說。
如果現實工作中真的遇見DKA+ARF的患者怎麼辦呢？
The presence of diabetes poses certain particular problems in the management of ARF. Prompt institution of dialysis is important as the diabetic patient may tolerate uraemia less well. Diabetes must be well controlled as uncontrolled ketosis may worsen hyperkalaemia and metabolic acidosis. Insulin requirements are often altered, either being increased due to insulin resistance or decreased due to impaired clearance of circulating insulin。
簡直是火上澆油，儘快上透析，同時調整胰島素用量，更具體的治療方案，還是需要和腎內科醫生會診了。
後臺回復「hannibal" ，有精彩資源哦
這裡是靠譜的醫學詞彙平臺，有趣，有料。
你得到的不僅僅是醫學詞彙！
歡迎投稿：alphamedenglish@126.com
閱讀原文