Ketoacidosis: A Diabetes Complication

Written by Bonnie Sanders Polin, PhD

Ketoacidosis can affect both type 1 diabetes and type 2 diabetes patients.  It's a possible short-term complication of diabetes, one caused by hyperglycemia—and one that can be avoided.

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are two of the most serious complications of diabetes. These hyperglycemic emergencies continue to be important causes of mortality among persons with diabetes in spite of all of the advances in understanding diabetes.

The annual incidence rate of DKA estimated from population-based studies ranges from 4.8 to 8 episodes per 1,000 patients with diabetes.

Unfortunately, in the US, incidents of hospitalization due to DKA have increased. Currently, 4% to 9% of all hospital discharge summaries among patients with diabetes include DKA.

The incidence of HHS is more difficult to determine because of lack of population studies but it is still high at around 15%. The prognosis of both conditions is substantially worsened at the extremes of age, and in the presence of coma and hypertension.

Why and How Does Ketoacidosis Occur?

The pathogenesis of DKA is more understood than HHS but both relate to the basic underlying reduction in the net effective action of circulating insulin coupled with a concomitant elevation of counter regulatory hormones such as glucagons, catecholamines, cortisol, and growth hormone.

These hormonal alterations in both DKA and HHS lead to increased hepatic and renal glucose production and impaired use of glucose in peripheral tissues, which results in hyperglycemia and parallel changes in osmolality in extracellular space.

This same combination also leads to release of free fatty acids into the circulation from adipose tissue and to unrestrained hepatic fatty acid oxidation to ketone bodies.

Some drugs can affect these processes. Medications that affect carbohydrate metabolism such as corticosteroids, thiazides, and sympathomimetic agents may precipitate the development of both DKA and HHS.

Sometimes ketones are present in urine when blood sugar falls too low and the body has to use body fat to get energy. In young diabetic persons, psychological problems complicated by eating disorders  may be a contributing factor in 20% of recurrent ketoacidosis.

Factors that may lead to insulin omission in younger patients include fear of weight gain with improved metabolic control, fear of hypoglycemia, rebellion from authority, and stress stemming from having a chronic disease.

The most common precipitating factor in the development of DKA or HHS is infection. Other factors are cerebrovascular accident, alcohol abuse, pancreatitus, myocardial infarction, trauma, and drugs. Arule of thumb to understand DKA is that dehydration plus blood ketones equals DKA.

Ketoacidosis Diagnosis

The process of HHS usually evolves over several days to weeks, whereas the evolution of acute DKA in both type 1 and type 2 diabetes tends to be much shorter (<24h). Occasionally, a patient may develop DKA with no prior clues or symptoms.

Ketoacidosis Symptoms

The first symptoms appear within the first few hours:

The next symptoms which appear:

Differential diagnosis needs to rule out starvation and alcoholism as well as the other precipitation factors stated above.

Your physician should have prescribed urine test strips that will test for ketones. It is suggested that if your blood glucose levels reads above 249 mg/dlL that you test for ketones

When you are ill with the flu or a cold, test for ketones every 4 to 6 hours. Also, make sure you test for ketones if you have the symptoms outlined above.

When you arrive at the hospital, laboratory work to determine plasma glucose levels, blood urea nitrogen/creatinine, serum ketone, electrolytes, osmolality, urinalysis, urine ketones as well as arterial blood gas, complete blood count and throat, etc. if infection is suspected as well as HbA1c to help decide if poor control may be involved.

If low potassium is noted this must be addressed, as it can provoke cardiac dysrhythmia.

Ketoacidosis Treatment

Successful treatment of DKA and HHS requires correction of dehydration, hyperglycemia, and electrolyte imbalances as well as identification of comorbid events and, above all, patients monitoring.

Ketoacidosis Prevention

Many cases of DKA and HHS can be prevented by better access to medical care, proper education and better communication with health care providers during any illness.

Sick day management should be taught to all diabetic patients.

This should include specific information on:

Since we all get sick with colds and the flu at some time, we end this article with sick day rules and regulations. After reading this article, you are aware that controlling blood glucose levels when you have an infection can be difficult.

Once when I came down with walking pneumonia, I wound up taking my blood glucose levels every few hours and worked very hard to keep my levels anywhere near normal.

So when you're sick, plan ahead and do the following:

So that's the story about ketones and ketoacidosis, a short-term complication of diabetes. It can be dangerous, but if you are educated, you can control your blood glucose levels or prevent ketoacidosis, especially when you're sick.

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How to Avoid Diabetic Ketoacidosis