Letters

Table 1Percentage of antibody-positive

and -negative offspring of diabetic parents
who received vaccination

Vaccination
BCG
DPT
Polio
HI
MMR
FSME

Antibody
negative,
n = 251

Antibody
positive,
n = 29

6
92
89
32
78
9

0
95
95
28
71
3

Data are %.

than one positive antibody, 7 of 29 had

one positive antibody, and 8 of 29 showed
transient elevation of antibody positivity).
Four offspring with more than one positive islet cell antibody developed clinical
IDDM at the ages of 13, 21, 27 months,
and 5 years. With respect to vaccination
history we could not detect any significant
difference between antibody negative and
antibody positive offspring of diabetic parents as shown in Table 1.
Because of the possible role of
mumps vaccination in the induction of
islet cell antibodies we analyzed the
sequence of MMR vaccination and the
appearance of antibodies. In total, 59%
(17 of 29) of the cases developed antibodies before the MMR vaccination in
contrast to 41% (12 of 29) of offspring
after vaccination (P > 0.05). In offspring
of diabetic mothers, 55% (12 of 22) had
antibodies before and 45% (10 of 22)
after vaccination. In offspring of diabetic
fathers, 71% (5 of 7) had antibodies
before and 29% (2 of 7) after vaccination
(P > 0.05). Transient elevations of antibody levels were seen in 29% before and
in 25% after vaccination (P > 0.05). All
four cases who progressed to overt
IDDM, to date, developed antibodies
before the first dose of the MMR vaccination or the scheduled date of vaccination.
In summary, we find no evidence that
the MMR vaccine virus would trigger the
initiation of f}-cell autoimmunity in children of diabetic parents. When considering the multiple positive effects of regular
vaccination, we see no need that children
with a family history of IDDM should be
excluded from MMR vaccination. Moreover, our results show no significant relation between autoimmune phenomena in

pre-type I diabetes and overall vaccination

history (i.e., tuberculosis [BCG], diphteriapertussis-tetanus [DPT], poliomyelitis
[polio], hemophilus influenza [HI], and
tick-borne encephalitis [FSME]). These
findings do not suggest a major role of vaccines in the pathogenesis of IDDM.

Orange
Juice-Induced
Hyperkalemia in a
Diabetic Patient with
Chronic Renal Failure

ypoglycemia in diabetic patients is

commonly treated with foods such
as milk, orange juice, fruit, and graBABY-DIAB PARTICIPANTS nola bars (1). However, in addition to providing sugar, these foods also contain relatively large amounts of potassium. Herein
From the Diabetes Research Institute and Academic we report on a diabetic patient who develHospital Munchen-Schwabing, Munich, Germany.
oped life-threatening hyperkalemia after
Address correspondence to A.G. Ziegler, MD, Diaconsuming large amounts of orange juice
betes Research Institute, Kolner Platz, 1 D-80804
to treat hypoglycemia.
Munich, Germany. E-mail: anziegler@lrz.unimuenchen.de.
A 50-year-old African-American man
Participants of BABY-DIAB are listed in Roll et al. with diabetic nephropathy and chronic(6).
renal failure was admitted to the hospital
for acute upper gastrointestinal bleeding
from a duodenal ulcer. Medications
included torsemide (40 mg/day), atenolol
(50 mg/day), clonidine (0.4 mg/day), diltiReferences
azem
CD (360 mg/day), cisapride (30
1. Hyoty H, Hiltunen M, Reunanen A,
Leinikki P, Vesikari T, Lounamaa R, mg/day), lisinopril (40 mg/day), calcium
Tuomilehto J, Akerblom HK, The child- carbonate (3.9 g/day), famotidine (20
hood Diabetes in Finland Study Group: mg/day), and NPH insulin (20 U/day).
Decline of mumps antibodies in type 1 The serum creatinine ranged from 4.5 to
(insulin-dependent) diabetic children and 6.0 mg/dl, and the serum potassium
a plateau in the rising incidence of type 1 ranged from 4.2 to 5.1 mEq/1. On the 14th
diabetes after introduction of the mumps- hospital day the patient developed sympmeasles-rubella vaccine in Finland. Dia- tomatic hypoglycemia (serum glucose
betologia 36:1303-1308, 1993
<51 mg/dl). A nurse told him to drink
2. Helmke K, Otten A, Willems WR, Brockorange juice. Over the following 24 h the
haus R, Mueller-Eckhard G, Stief T,
Bertrams J, Wolf H, Federlin K: Islet cell patient consumed ~ 1 gallon of orange
antibodies and the development of dia- juice. Hypoglycemia resolved, but the
betes mellitus in relation to mumps infec- patient then complained of weakness. An
tion and mumps vaccination. Diabetologia electrocardiogram revealed sinus brady29:30-33,1986
cardia with first-degree heart block,
3. Dahlquist G, Gothefors L: The cumulative widening of the QRS interval, and peaked
incidence of childhood diabetes mellitus T waves. The serum potassium was 6.2
in Sweden unaffected by BCG vaccination. mEq/1, and the serum glucose was 106
MICHAEL HUMMEL, MD
ANETTE-G. ZIEGLER, MD

4.
5.

6.

DIABETES CARE, VOLUME 19, NUMBER 12, DECEMBER

Diabetologia 38:873-874,1995
Classen JB, Classen DC: Vaccines modulate IDDM. Diabetologia 39: 500-502,
1996
Ziegler AG, Hillebrand B, Rabl W,
Mayrhofer M, Hummel M, Mollenhauer
U, Vordemann J, Lenz A, Standl E: On the
appearance of islet-associated autoimmunity in offspring of diabetic mothers: a
prospective study from birth. Diabetologia
36:402-408, 1993
Roll U, Christie MR, Fiichtenbusch M,
Payton MA, Hawkes CJ, Ziegler AG: Perinatal autoimmunity in offspring of diabetic parents: the German multicenter
'BABY-DIAB' study: detection of humoral
immune responses to islet antigens in early
childhood. Diabetes 45:967-973,1996

Table 1Potassium and carbohydrate

contents of juices at Hines Veterans Affairs
Hospital

Cranberry juice
Grape juice
Pineapple juice
Orange juice
Prune juice

Potassium

Carbohydrate
(g)

26
26
170
236
370

17
16
17
13
20

Values given are for a 4-oz serving of canned or

bottled juice.

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1996

Letters

mg/dl. Treatment with calcium gluconate,

glucose and insulin, and a potassiumexchange resin was instituted, with
prompt resolution of hyperkalemia.
Elevated serum potassium levels are
common in diabetic patients. Etiologies
include chronic renal failure (as was present in our patient), hyporeninemic hypoaldosteronism, and the use of medications
that decrease potassium excretion, such as
potassium-sparing diuretics, nonsteroidal
anti-inflammatory drugs, heparin, and
angiotensin-converting enzyme inhibitors
(our patient was taking lisinopril).
Absolute or relative insulin deficiency will
inhibit uptake of potassium by cells, thus
decreasing tolerance to an acute potassium
load (2). Moreover, hyperglycemia itself
can result in hyperkalemia in patients with
diabetes and hypoaldosteronism (3). Thus,
administration of foods with a high sugar

and potassium content to a diabetic patient

with impaired potassium tolerance may
raise serum potassium levels, resulting in
severe hyperkalemia.
As depicted in Table 1, fruit juices
have widely varying potassium contents.
Although we recognize that the development of hyperkalemia in our patient
resulted from the extremely large amount
of orange juice consumed (1 gallon contains ~7.6 g of potassium) in the face of
impaired potassium tolerance, we believe
it is unncessary and potentially dangerous
to treat hypoglycemia with a juice that
contains large amounts of potassium. We
now use cranberry juice to treat symptomatic hypoglycemia in all diabetic patients
with renal insufficiency at our hospital.
KAILI FAN, MD
DAVID J. LEEHEY, MD

From the Department of Medicine, Veterans Affairs

Hospital, Hines, Illinois.
Address correspondence to D.J. Leehey, MD,
VA Hospital (111-L), Hines, IL 60141. E-mail:
djleehey@aol.com.

References
1.

2.

3.

Orland MJ: Diabetes mellitus. In Manual of

Medical Therapeutics. 27th ed. Woodley M,
Whelan A, Eds. Boston: Little, Brown,
1992, p. 375-399
Cox M, Sterns RH, Singer I: The defense
against hyperkalemia: the roles of insulin
and aldosterone. N Engl J Med 299:525532,1978
Goldfarb S, Cox M, Singer I, Goldberg M:
Acute hyperkalemia induced by hyperglycemia: hormonal mechanisms. Ann
Intern Med 84:426-432, 1976

Errata
Suzuki Y, Tsukuda K, Atsumi Y, Goto Y, Hosokawa K, Asahina T, Nonaka I, Matsuoka K, Oka Y: Clinical picture of a case
of diabetes with mitochondrial tRNA mutation at position 3271 (Letter). Diabetes Care 19:1304-1305, 1996
Because of a production error, the citation to the figures was omitted. On page 1304, column 1, second paragraph, line 8, the citation should read, "Diabetes congregated in the maternal line, and he, his sister, and his mother were found, on analysis of hair follicles, to have the 3271 mutation (Figs. 1 and 2) (1)."
Mazzella M, Cotellessa M, Bonacci W, Bruno C, Serra G: Neonatal diabetes and DQB1 typing (Letter). Diabetes Care
19:1308, 1996
Because of a production error, the citation to the table was omitted. On page 1308, column 1, third paragraph, line 3, the citation
should read, "We retrospectively performed HLA-DQB1 typing on three patients with neonatal diabetes (Table 1)."

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1996