Diabetic ketoacidosis

Alternative names
DKA; Ketoacidosis; Diabetic coma

Definition
Diabetic ketoacidosis is a complication of diabetes mellitus caused by the buildup of by-products of fat metabolism (ketones), which occurs when glucose is not available as a fuel source for the body.

Causes, incidence, and risk factors

People with diabetes lack sufficient insulin, a hormone the body uses to process glucose (a simple sugar) for energy. When glucose is not available, body fat is broken down instead. The by-products of fat metabolism are ketones. When fat is metabolized, ketones build up in the blood and “spill” over into the urine. A condition called ketoacidosis develops when the blood becomes more acidic than body tissues.

Blood glucose levels become elevated (usually higher than 300 mg/dL) because the liver produces glucose to try to combat the problem and because cells cannot take up that glucose without insulin. Diabetic ketoacidosis may lead to the initial diagnosis of type 1 diabetes, as it is often the first symptom that causes the person to come to medical attention. It can also be the result of increased insulin needs in someone already diagnosed with type 1 diabetes. Infection, trauma, heart attack, or surgery can lead to diabetic ketoacidosis in such cases.

People with type 2 diabetes usually develop ketoacidosis only under conditions of severe stress. Poor compliance with diet and treatment is usually the cause when episodes are recurrent.

Symptoms

     
  • Frequent urination or frequent thirst for a day or more  
  • Fatigue  
  • Nausea and vomiting  
  • Muscular stiffness or aching  
  • Mental stupor that may progress to coma  
  • Rapid deep breathing  
  • Fruity breath (breath odor)

Additional symptoms that may be associated with this disease:

     
  • Headache  
  • Decreased consciousness  
  • Breathing - rapid  
  • Breathing difficulty - lying down  
  • Low blood pressure  
  • Appetite - loss  
  • Abdominal pain

Signs and tests

     
  • Low blood pressure  
  • Rapid heart rate  
  • Signs of dehydration  
  • High blood glucose (above 300 mg/dL)  
  • Presence of glucose and ketones in urine by home or office testing  
  • Serum potassium (may be elevated)  
  • Serum amylase (may be elevated)  
  • Arterial blood gas (reveals pH of less than 7.3)

This disease may also alter the results of the following tests:

     
  • Urine pH  
  • Sodium - urine  
  • Serum sodium  
  • Potassium - urine  
  • Serum phosphorus  
  • Serum magnesium - test  
  • CSF collection  
  • CO2

Treatment

The goal of treatment is to correct the elevated blood glucose level by giving additional insulin, and to replace fluids lost through excessive urination and vomiting. A person with diabetes may be able to recognize the early warning signs and make appropriate corrections at home before the condition progresses.

If ketoacidosis is severe, hospitalization is required to control the condition. Insulin replacement will be given, fluid and electrolytes will be replaced, and the cause of the condition (such as infection) will be identified and treated.

Expectations (prognosis)
Cell damage from acidosis can lead to severe illness or death. Improved therapy for young diabetics has decreased the death rate associated with this condition. However, it remains a significant risk in the elderly and in people who fall into a profound coma when treatment has been delayed.

Complications

     
  • Heart attack and tissue death of bowel tissue due to associated low blood pressure  
  • Renal failure

Calling your health care provider
This condition can become a medical emergency. Call your health care provider if you notice early symptoms of diabetic ketoacidosis.

Go to the emergency room or call the local emergency number (such as 911) if nausea, vomiting, fruity breath, mental stupor, difficulty breathing, or decreased consciousness occur.

Prevention
Diabetics should learn to recognize the early warning signs and symptoms of ketoacidosis. Measurement of urine ketones in people with infections or people on insulin pump therapy can give more information than glucose measurements alone.

Johns Hopkins patient information

Last revised: December 5, 2012
by Potos A. Aagen, M.D.

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