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Diabetic Ketoacidosis PRIMER Diabetic ketoacidosis Ketan K. Dhatariya1,2, Nicole S. Glaser3, Ethel Codner4 and Guillermo E. Umpierrez5 ✉ Abstract | Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present — ‘D’, either elevated blood glucose levels or a family history of diabetes mellitus; ‘K’, the presence of high urinary or blood ketoacids; and ‘A’, a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy , electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology , pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children. Circulatory volume Diabetic ketoacidosis (DKA) is the most common acute acid decarboxylase and protein tyrosine phosphatase depletion hyperglycaemic emergency in people with diabetes mel- autoantibodies, as those who present with hyperosmo- A reduction in intravascular litus. DKA is the consequence of an absolute (that is, lar hyperglycaemic state (HHS), and their β-cell func- and/or extracellular fluid total absence of) or relative (that is, levels insufficient tion recovers with restoration of insulin secretion quickly volume, such that there may 2 be an inability to adequately to supress ketone production) lack of insulin and con- after treatment . Thus, individuals with ketosis-prone perfuse tissue. comitant elevation of counter-regulatory hormones, T2DM can often go back to oral glucose-lowering medi- usually resulting in the triad of hyperglycaemia, met- cation without the need for continuing insulin therapy. abolic acidosis and ketosis (elevated levels of ketones DKA is associated with significant morbidity and high in the blood or urine; a serum ketone concentration of utilization of health-care resources, accounting for >3.0 mmol/l), often accompanied by varying degrees 4–9% of all hospital discharges among those with a diag- of circulatory volume depletion. DKA occurs mostly in peo- nosis of diabetes mellitus as the primary cause for their ple with uncontrolled type 1 diabetes mellitus (T1DM; acute hospital admission4. DKA remains an expensive which results from the autoimmune destruction of the condition to treat. In the USA, a single episode of DKA is β-cells of the islets of Langerhans) but can also occur in estimated to cost ~US$26,566 (REF.5). In the UK, the cost adults with poorly controlled type 2 diabetes mellitus of one DKA episode is estimated to be £2,064 in adults (T2DM; a result of impaired insulin secretion or action) and £1,387 in adolescents (11–18 years of age)6,7. 1Elsie Bertram Diabetes under stressful conditions, such as acute medical or sur- The criteria used to define DKA vary in different Centre, Norfolk and Norwich gical illnesses, and, in adolescents, in new-onset T2DM parts of the world (Table 1). In 2001, the American University Hospitals NHS (also known as ketosis-prone T2DM) (FIG. 1). Although Diabetes Association (ADA) expanded the definition of Foundation Trust, Colney any illness or physiological stress can precipitate DKA, DKA to include mild metabolic acidosis, hyperglycae- Lane, Norwich, Norfolk, UK. the most frequent causes are infections, particularly mia and positive ketone tests8,9 (Table 1). Although all the 2Norwich Medical School, urinary tract infections and gastroenteritis1,2. definitions of DKA concur by saying that all three com- University of East Anglia, Norfolk, UK. DKA was previously considered to be a key clinical ponents need to be present, the glucose concentrations feature of T1DM but has been documented in children and method of documenting ketosis vary. Additionally, 3Department of Pediatrics, 2,3 University of California and adults with newly diagnosed T2DM . Although all guidelines agree that venous or arterial pH should Davis, School of Medicine, ketosis-prone T2DM can occur in all populations, be <7.30. Early diagnosis and treatment are paramount Sacramento, CA, USA. epidemiological data suggest that people of African or to improve patient outcomes. In developed countries, 4Institute of Maternal and Hispanic origin seem to be at greater risk2; this predispo- the risk of death resulting from DKA is <1% in children Child Research, School of sition probably has a genetic component, but this hypoth- and adults10,11, whereas, in developing countries, mortal- Medicine, University of Chile, Santiago, Chile. esis has yet to be elucidated. Most often, individuals with ity is much higher, with reported death rates as high as ketosis-prone T2DM have obesity and a strong family 3–13% in children12. Among adults, DKA-related deaths 5Diabetes & Endocrinology, Emory University School of history of T2DM as well as evidence of insulin resistance. occur primarily in older persons (>60 years of age) or 1 Medicine, Atlanta, GA, USA. Despite presenting with DKA and decreased insulin con- in those with severe precipitating illnesses . In children, ✉e-mail: [email protected] centrations, on immunological testing, these individu- most DKA-related deaths result from cerebral injuries https://doi.org/10.1038/ als have the same frequency of the typical autoimmune or cerebral oedema. Evidence-based treatment strate- s41572-020-0165-1 markers of T1DM, such as islet cells, insulin, glutamic gies include correction of fluid deficits, insulin therapy, NATURE REVIEWS | DISEASE PRIMERS | Article citation ID: (2020) 6:40 1 0123456789(); PRIMER First detailed Kussmaul breathing described High-dose Low-dose insulin protocols First ADA guideline on report of insulin introduced DKA treatment diabetic coma Acetoacetate and β-hydroxybutyrate therapy used in clinical practice introduced Rate of fluid administration UK guidelines published in children questioned 1800 1857 1870 – 1880 1921 1923 1930 – 1970 1971 – 1990 2001 – 2009 2010 – 2019 Identification of DKA mortality >95% Mortality <1% acetone in the Discovery urine of patients of insulin First successful case of DKA treatment First RCT of fluid protocols in children reported Fig. 1 | The history of DKA. The first reports of diabetic coma date only a few patients living longer than a few months. In subsequent decades, back to the early 1800s and included isolated cases of children and the mortality decreased, reaching <1–2% since the 2010s in developed adults with previously undiagnosed or established diabetes who presented countries1,8. It was not until in the 1970s that low-dose intravenous insulin with rapid onset symptoms of hyperglycaemia that led to coma and infusions were introduced following data showing that they lowered death269. In 1857 , the presence of acetone was identified in the urine of an glucose and ketone concentrations just as well as higher doses274. The first individual presenting with diabetic coma270. Two decades later, the German American Diabetes Association (ADA) guideline was published in 2001 and physician Adolf Kussmaul and colleagues reported severe dyspnoea the first edition of the UK guidelines was published in 2011. In 2018, the first (hyperventilation) in patients271. A decade later, Stadelmann reported that randomized controlled trial (RCT) of fluid replacement in children showed the urine of most patients with diabetic coma contained large quantities of no differences in acute or post-recovery neurological outcomes in children β-hydroxybutyrate in addition to acetoacetate272. The mortality associated with DKA treated with rapid versus slower volume correction using either with diabetic ketoacidosis (DKA) was >90% in the pre-insulin era273, with 0.9% or 0.45% saline159. potassium repletion and correction of the precipitating individuals with a genetic predisposition might be at factor. The other hyperglycaemic emergency that can greater risk of developing ketosis-prone T2DM. occur is HHS, which has a distinct pathophysiology to Epidemiological studies in the USA and Europe DKA (BOX 1). revealed increasing hospitalizations for DKA in This Primer aims to provide up-to-date knowledge adults10,13,25. In 2014, the US Centers for Disease Control on the epidemiology, pathophysiology, clinical presenta- and Prevention reported a total of 188,950 cases of DKA10. tion and management of DKA. In addition, we also dis- Between the years 2000 and 2009, an average decline of cuss prevention measures after discharge in adults and 1.1% in the annual age-adjusted DKA hospitalization children with DKA. rate was noted among people with any form of diabe- tes mellitus10. However, the estimated average annual Epidemiology hospitalization rate increased to 6.3% between 2009 As the majority of people with DKA are hospitalized, and 2014, that is, a rise of 54.9% (from 19.5 to 30.2 per most epidemiological data come from hospital dis- 1,000 persons). This increase was observed across all age charge coding. Among adults, two-thirds of episodes of groups and sexes. The highest hospitalization rates were DKA occur in people diagnosed with T1DM and one- for individuals <45 years of age, a finding that might third occur in those with T2DM3,11,13. In children (<18 years be attributed to poor control (44.3 per 1,000 persons of age), DKA commonly occurs at the initial diagnosis of in 2014), and lowest for persons >65 years of age for T1DM, with incidence varying in different popu lations reasons unknown (<2.0 per 1,000 persons in 2014)10. from 13% to 80%14–16. Adolescents with T2DM also pres- The causes of increased DKA hospitalizations are not ent with DKA, although less frequently than children clear but might relate to changes in DKA definition8,9, with T1DM14. In addition, the frequency of DKA at diag- the use of new medications associated with increased nosis correlates inversely with the frequency of T1DM DKA risk and lower thresholds for hospitalization (that in the population, suggesting that the more frequently is, admission of individuals with less serious disease)10,13.
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