A Dad Didn’t Brush His Teeth for 40 Days. This Is What Happened To His Kidneys.
CJ is a 46 year old man, presenting to the emergency room with excessive thirst, abdominal
discomfort, and shortness of breath. He tells the admitting nurse that he had lost 15 pounds
over the last 2 weeks and had developed a pounding toothache.
You see, CJ was a dad who lost everything. Earlier in his life, he was a successful engineer,
with a happy family.
Five years ago, on his 41st birthday, CJ lost his 5 year old son in a sudden freak accident.
He returned to work from bereavement leave, only to find he was laid off. His wife, unable
to cope with tragedy, left him before year’s end.
Bankrupt and unable to find new work, CJ was forced in to government housing to a poor
part of town. He found comfort and affordability in certain foods and gained over 250 pounds (114kg)
in 4 years.
About 2 months ago, CJ’s mother, his last sense of hope in family, passed away. In his
sadness, he laid in bed all day, only getting up to go to the convenience store to eat.
He no longer cared for his own personal hygiene— no longer brushed his teeth, no longer bathed.
Over the next few weeks, he noticed something wrong when he had an unquenchable thirst.
Because juice is fruit, it must be healthy, so drink more of it, he thought.
One day, he drank 2 gallons juice and urinated every 15 minutes. Just a lot of extra liquid, he thought.
On the surface, CJ didn’t appear to be well. He had glucosuria, or sugar in his urine.
This was combined with his polydipsia, his unquenchable thirst, and polyuria, his frequent
urination. His face was turgid- swollen and bloated. Evaluation of his oral cavity found
an infected tooth, which inflamed his oral mucosa and formed multiple pustules along
his gums, all because he no longer found it necessary to brush his teeth.
A blood test reveals CJ’s blood glucose level is 800 mg / dL, more than 10 times that
of normal.
In the emergency room, CJ becomes more lethargic. His toothache was pounding. His blood pressure
was dropping, and in the wait for medical care, he finally collapses into coma.
Given this past history, there’s several clues as to what’s going on. Most immediately,
CJ is suffering from hyperglycemic crisis. Hyper meaning high. Glyce referring to glucose,
or sugar, the primary source of energy for cells, and emia meaning presence in blood.
High glucose presence in blood and crisis meaning there was an underlying cascade of
events that brought about CJ’s metabolic derangement, which leads us to the first clue.
Because he was urinating every 15 minutes, there was a substantial net flow of water
out of his body. His urine has a lesser concentration of sugar in it compared to the juice, which
means that glucose is accumulating and concentrating in his blood. We can prove this
Because CJ weighed over 400 pounds at admission, his estimated blood volume was about 9 liters.
Given his blood glucose level of 800 mg / dL, there are 72 grams, almost a one fifth pound
of sugar, floating around in the blood. The average amount for a healthy man weighing
around 175 pounds (79.4kg) is 4 grams, 18 times less than CJ.
Because CJ drank 2 gallons (7.57 L) of juice which amounted to 850 grams of sugar, and 72 are
present in his blood, then where are the other 700 grams?
Well, there’s a bit of basic human physiology to be known here. When you eat, food goes
into your stomach, then to the small intestines, where fats, proteins and sugars, absorb through
the liver, then are delivered to the body through the blood. Glucose enters cells because
the body releases a hormone named insulin into circulation in response to food, shifting
sugar into muscle, liver, and fat tissue for storage.
The problem with CJ is that both his diet and his class 3 obesity, defined by his body
mass index, allowed for massive disturbances in high blood glucose levels, based on his
choice and amount of foods. This caused an overabundance of insulin to be in his blood constantly.
Because cells don’t want this continuous influx of glucose, they downregulate,
or decrease the number of insulin receptors, meaning they won’t accept as much sugar
from the blood, leaving it floating around as they become increasingly insulin resistant.
Over the last 4 years, CJ, through his diet of bountiful sugary and fatty foods, saturated
his tissues with glucose and his body converted those stores to fat. Unable to handle the
overabundance of sugar, the body left it in the blood to accumulate, where it inevitably
overloaded the kidneys and began to spill into the urine explaining CJ’s glucosuria.
This is the chronic, or long-term, physiologic consequence of CJ’s gross hyperglycemia,
but there is also a life-threatnening chemical consequence as well.
CJ is in hyperosmolar hyperglycemic state. Hyperosmolar, describing the chemistry responsible
for what’s happening.
The interesting thing about glucose is that it creates an osmotic gradient. Which means
wherever it is, water will flow towards it.
In this small science experiment, I fill an outside pool with sugar water. I submerge
a tube filled with distilled, sugar free, water, and you’ll see that water leaves
the tube, that water flows towards the sugar.
So lets go back to the name of CJ’s problem, hyperosmolar hyperglycemic state. Because
there’s a large glucose presence in blood, sugar is drawing water out of his cells, exerting
a hyperosmolar effect. Because his cells are losing water, his body thinks he is dehydrated
and release signals to his brain to alert him of thirst, explaining his polydipsia.
Because water is getting drawn into his intravascular space, it increases the flow of water to the
kidneys, causing them to filter more urine explaining his polyuria.
The hyperglycemia begins to draw water out of his brain, dehydrating it, causing his
neurological deficits, resulting in coma. As his cells begin to dry out and he persists
in excessive urination, his body becomes massively dehydrated, decreasing perfusion to the already
dried out kidneys, and causing acute kidney injury. With the failure of kidneys, what
should be CJ’s urine is now floating around in his blood, rotting his bones through an
imbalance of calcium and phosphate, altering his brain chemicals through excess nitrogen,
and disrupting the electrophysiology of the heart through potassium. All because his body
could no longer handle glucose.
At this point, it is impossible to directly remove the sugar from his blood. Even if we
drained CJ’s body and transfused in fresh, euglycemic blood, it too would become hyperglycemic
to the point of crisis because the pathogenesis of hyperosmolar hyperglycemic state is metabolic
in nature. All of this precipitated by CJ’s abscessed tooth.
Because CJ hadn’t brushed his teeth for 40 days, his tooth became inflamed and infected.
This infection seeped into his gums and began to spill into his systemic circulation, and
spread throughout his body, causing septicemia. A bacteria presence in blood. This forced
his immune system to activate, and caused adrenaline to release
in response to the physiologic stress.
Because adrenaline is usually released when you get scared or excited, it forces the liver
and muscles, sites of storage for glucose, to quickly release sugar into the blood. This
makes sense because to fuel a fight or flight response, you need sugar in blood for cells
to generate mechanical energy. But its release is inappropriate in CJ meaning his
hyperglycemia was not only onset by the juice he drank and his overall diet, but was amplified
by his own body through physiologic stress induced by poor oral hygiene. If this continues
untreated, the electrolyte abnormalities onset by renal failure through dehydration will
cause cardiac arrhythmias and lead to sudden death.
The notion of metabolic derangement arising from hyperglycemic crisis was observed thousands
of years ago. In 1500 BC, ancient Egyptian physicians wrote about a "too great emptying
of the urine" that attracted ants. It was later found that sugar was responsible for attracting
the insects. Ancient Chinese medical texts describe sugar urine disease, who’s pronunciation
tang niao bing preserved into Japanese and Korean. We know this today to be diabetes
and this hyperglycemic crisis alone is sufficient to diagnose CJ with type 2 diabetes, the disorder
where the body does create insulin but does not respond to it. Contrast with type 1 diabetes
where the body doesn’t create insulin at all.
The notion of diabetic coma was first described in western literature in 1828 by German physician
August von Stosch who described severe polydipsia, polyuria and glucosuria followed by decline
in mental status leading to death.
In the early 1900s, a diabetes diagnosis was a death sentence. Without insulin patients
would inevitably suffer hyperglycemia from eating, causing dehydration, kidney injury,
and coma, leading to death. It was only in 1921 when Canadian physician Frederick Banting
and group extracted insulin from cows that diabetes became a chronic treatable illness.
It wasn’t until 1957 when humans finally understood that the pathogenesis and etiology
of coma and kidney injury in hyperglycemic hyperosmolar state were due to extracellular
hypertonicity and cellular dehydration arising from underlying metabolic derangement accompanied
with a major precipitating factor.
For CJ, we treat his condition first by treating his infection with antibiotics and in his
case, the abscessed tooth was removed. Because his blood was hyperosmolar due to glucose,
we dilute his blood by infusing water into his veins. Rehydration efforts will amount
to as much as 20 liters given over 48 hours. This will mitigate his dehydration and reduce
the plasma osmolality that was onset by hyperglycemia and begin to perfuse the kidneys, delivering
oxygen to the tissue and alleviating acute injury, allowing them to filter urine and
remove wastes, while restoring water back into the cells.
With the physiologic stress removed on treatment of his tooth, some insulin sensitivity will
be restored and administering insulin intravenously will allow more water to shift back into the
cells, as well as replete potassium, an electrolyte which was forced out of the cell
during hyperglycemic crisis and excreted in large quantities during polyuria.
Today, we have sophisticated therapies and techniques to treat diabetes. We have drugs
that sensitize cells to insulin. Before 1977, insulin that was originally derived from grinding
pig and cow pancreas, would inevitably cause allergic reactions after long term use. After
1980, we have genetically engineered E. coli bacteria with recombinant human DNA, enabling
them to produce human insulin in unadulterated form. This paved the way for short and long
acting insulin analogs to alleviate acute and chronic aberrations in glycemic levels
and helps maintain glucose control in the elderly, where hypoglycemia onset from incorrect
insulin doses will cause dizziness and loss of consciousness leading to falls, shattering
bones and hips, leading to increased mortality in the elderly.
Despite all of these techniques, tragedies from underlying metabolic derangements will
still happen from more factors than anyone can image. Whether it be a gap or dislocation
in medical care, a disruptive culture, or simply a decline in lifestyle for various
reasons, the causes are not simple. The data today shows, as metabolisms slow when one
begins to age, high body fat percentage bordering on obesity, a decreased volume of total body
water and atrophy of skeletal muscle, is almost inevitable for a majority of people as they
enter into elderhood. But that doesn’t mean to ignore your health when you are young either.
With continued monitoring in the ICU, counseling and social support to bring CJ back from the
brink, and a new hope to regain status in his life once again
CJ was able to make a full recovery.
Thank you so much for watching. Take care of yourself. And Be well.