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.
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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.