Diabetic Ketoacidosis

DKA Diagnostic Criteria

1. Diabetes/hyperglycemia

Glucose ≥200 mg/dL (11.1 mmol/L) OR prior history of diabetes

2. Ketosis

β-Hydroxybutyrate concentration ≥3.0 mmol/L OR urine ketone strip 2+ or greater

3.  Metabolic Acidosis

pH <7.3 and/or bicarbonate concentration <18 mmol/L

Physiology

• Ketones = Alternative Fuel to Glucose
• Made by burning fat (lipolysis)
• Lipolysis is suppressed by insulin
• In the presence of insulin, ketones should not be generated

DKA occurs when both relative insulin deficiency and excess counter-regulatory hormones are present.

1. Relative insulin deficiency

Insulin omission

Beta cell failure

Insulin resistance

2. Excess counter-regulatory hormones:

Fasting

Metabolic stress

Comorbidity

Ketoacidosis – Who is at Risk?

➤ Type of Diabetes: Type 1 Diabetes, Type 2 Diabetes, Ketosis-Prone Type 2 Diabetes (KPDM), Other Insulin Deficient States

➤ Individual Factors: SGLT-2 Inhibition, Unwell / Catabolic State, Ketogenic Diet, Prolonged Fasting or Starvation

3 Pillars of Management

• Intravenous fluids
• Insulin
• Potassium

Other important points

• Check electrolytes, renal function, venous pH, osmolality, and glucose every 2–4 h until stable.
• After resolution of DKA or HHS and when patient can eat and drink, initiate s.c. multidose insulin regimen.
• To transfer from i.v. to maintenance s.c. insulin, continue i.v. insulin infusion for 1–2 h after s.c. insulin.
• ⚠ Bicarbonate should only be considered if pH is < 7.0
• ⚠ Phosphate should not be given unless there is muscle weakness, respiratory compromise, and a phosphate < 1.0 mmol/L

Criteria for Resolution of DKA 

• • plasma ketone <0.6 mmol/L and
  • venous pH ≥7.3 or
  • bicarbonate ≥18 mmol/L

-urinary ketone measurement should be avoided as a criterion of DKA resolution.

Other scenarios besides Type 1 diabetes where a diabetes patient can present with DKA:

LADA (Latent autoimmune diabetes of adult)- Key features

• Adult onset
• Presence of islet ab
• No immediate insulin requirement at diagnosis
• Progresses more rapidly to insulin dependence

DKA in a patient on SGLT2 inhibitor- Risk factors

• Prolonged fasting
• Low-carb diet
• Dehydration, infection, major surgery

DKA in type 2 diabetes-Risk factors

• Long duration
• Catabolic stress
• Precipitant SGLT2 inhibitor

Ketosis-prone diabetes

• Presents with Diabetic Ketoacidosis (DKA)
  • Sudden onset of hyperglycemia with ketones and acidosis.
  • Similar to type 1 diabetes in presentation.
• Occurs in People Without Prior Diabetes Diagnosis
  • Many patients present with DKA as their first sign of diabetes.
• Common in Overweight or Obese Individuals
  • Often seen in individuals with type 2-like features (insulin resistance, obesity, family history).
• Seen More Often in Certain Ethnic Groups
  • Higher prevalence in people of African, Hispanic, or Asian descent.
• Initially Requires Insulin
  • Patients need insulin therapy to treat DKA.
• Some Can Discontinue Insulin Later
  • Many patients recover beta-cell function and become insulin-independent after weeks or months.
• Autoantibody Status is Usually Negative
  • Most are GAD/IA2 antibody-negative, unlike type 1 diabetes.
• C-peptide Levels Can Recover
  • Indicates preserved or recovering pancreatic function.
• Risk of Recurrence of DKA
  • Some may relapse into ketosis or DKA, especially with poor glycemic control.
• Heterogeneous Disease
  • Falls into a spectrum between type 1 and type 2 diabetes — classified by autoantibody and beta-cell function status (A+/A–, B+/B–).