Diabetic Ketoacidosis Explained

One of the most notorious complications of diabetes is diabetic ketoacidosis, or DKA.

First described in the late 19th century, DKA represented something close to the ultimate diabetes emergency: In just 24 hours, people can experience an onset of severe symptoms, all leading to coma or death.

But DKA also represents one of the great triumphs of the revolution in diabetes care over the last century. Before the discovery of insulin in 1920, DKA was almost invariably fatal, but the mortality rate for DKA dropped to below 30 percent within 10 years, and now fewer than 1 percent of those who develop DKA die from it, provided they get adequate care in time.

Don’t skip over that last phrase, because it’s crucial: DKA is very treatable, but only as long as it’s diagnosed promptly and patients understand the risk.

What is DKA?

Insulin plays a critical role in the body’s functioning: it tells cells to absorb the glucose in the blood so that the body can use it for energy. When there’s no insulin to take that glucose out of the blood, high blood sugar (hyperglycemia) results.

The body will also start burning fatty acids for energy, since it can’t get that energy from glucose. To make fatty acids usable for energy, the liver has to convert them into compounds known as ketones, and these ketones make the blood more acidic. DKA results when acid levels get too high in the blood.

There are other issues too, as DKA also often leads to the overproduction and release of hormones like glucagon and adrenaline. All the symptoms of DKA are signs of the kind of chaos the body is thrown into as it tries to compensate for all these hormonal and chemical imbalances.

What are the symptoms of DKA?

DKA symptoms can often arise slowly at first; these early symptoms include:

• Thirst and dehydration

• Dry Mouth

• Frequent Urination

If untreated, the more severe symptoms of DKA can occur fairly rapidly (in a few hours after the onset of vomiting). These severe, rapid-onset symptoms include:

• Nausea

• Vomiting

• Sever abdominal pain

• Breathing trouble

• Confusion and extreme fatigue

Does DKA occur in both type 1 and type 2 diabetes?

Generally speaking, DKA affects people with type 1 diabetes: Somewhere between 5 and 8 of every 1,000 people with type 1 diabetes develops DKA each year, resulting in about 135,000 hospital admissions per year. It’s much rarer for people with type 2 diabetes to develop DKA, since they usually have some remaining insulin production.

A full list of DKA symptoms can be found at the ADA’s page here.

Who is at risk of developing DKA?

• People who are unaware they have diabetes. Indeed, as many as 30% of children with type 1 diabetes learn they have the disease only after developing DKA.

• People with diabetes who are sick. Illness often increases the need for insulin; and it also reduces appetite and, as a result, can lead to increased ketone levels. The ADA recommends checking ketones every 4 to 6 hours when sick.

• People with irregular eating habits. Skipping meals or inconsistent insulin regimens can result in heightened ketone levels, which means that people with eating disorders are at particular risk.

• Younger people; according to the CDC, DKA hospitalizations occurred in at nearly ten-fold the rate in people with diabetes aged 0-45 compared to in those aged 45-65.

What can patients do to prevent DKA?

Keeping blood sugars in the normal range can help prevent DKA: 70-180 mg/dl is ideal. Risk of DKA increases substantially when blood glucose levels exceed 240 mg/dl. Sticking with healthy, regular eating patterns and taking medications at the right times are also critical for preventing DKA.

It’s possible to check ketone levels with a simple, over-the-counter urine test strips (see an example here) or a ketone meter. It’s a good idea to start checking ketone levels when blood glucose is over 240 mg/dl. Again, your healthcare provider can let you know when this is worth doing and what specific ketone levels would be a cause for concern.

How is DKA treated?

Above all, if your ketone levels are high enough to put you at risk of DKA, be prepared to act quickly in getting emergency care. The treatment for DKA involves dealing with the various symptoms, which means:

• Rehydration

• Replacement of lost electrolytes

• Regular administration of insulin

For more information on ketoacidosis, please see this page from the ADA.