Diabetic Ketoacidosis: DKA – Causes, symptoms, Treatment.

While hypoglycemia is low blood sugar, hyperglycemia is high blood sugar and can lead to a serious condition known as diabetic ketoacidosis. Usually referred to by its acronym DKA, it is more common in those who have Type 1 diabetes (T1D) but does occur in those who have type 2 diabetes (T2D) also.[1]

What is DKA?

A dynamic relationship exists between glucagon and insulin. Glucagon works to get glucose into the blood stream, while insulin acts to get the glucose out of the blood stream and into the cell where it can be used as energy. If, as in T1D, insulin is almost nonexistent, the blood sugar rises and is not absorbed by the cells where it can be used as energy by the body. To compensate, the body begins to breakdown the body fat into fatty acids as it tries to find an alternative energy source. The fat metabolism forms ketones, and the blood becomes acidic as a result.[2]

It is natural for the body to rely on fat metabolism as a source of energy when glucose is not available. However, an unusual quantity of fatty acids suddenly and unexpectedly entering the bloodstream cannot be fully metabolized. As a result, the fat breakdown halts half way through the cycle leaving fat at the ketone level. This is why the breath has a slight the smell of acetone in these instances– the odor frequently referred to as a fruity smell.[3]

Diabetic ketoacidosis occurs when the fat metabolism leads to the formation of ketones, while the liver is trying to generate more and more glucose because insulin is not present. The blood glucose levels rise dangerously high as a result.

What Causes DKA?

For 5% to 10% of those who develop AKA there is no known cause. Research has, however, identified several events that can trigger DKA in a person who has diabetes. The most common for both children and adults, according to research and medical studies are the following:

  • Infection that includes responses like diarrhea, vomiting, and/or high fever (40%)
  • Insufficient or overlooked insulin (25%)
  • Recently diagnosed or unsuspected diabetes (15%)
  • Heart  attack or stroke
  • Trauma
  • Stress
  • Alcohol or drug abuse
  • Surgery

In children and young adults, multiple factors influence the risk of developing DKA. This is particularly applicable for those with type 1 diabetes. The most common factors are:

  • The presence of another illness – This has been true for roughly a third of the cases.
  • There has been an unrecognized need for more insulin.
  • Inadequate supervision of glucose control. Insulin was either omitted or an inadequate amount was administered
  • In adolescents, eating disorders lead to skipping insulin doses

Who gets DKA?

DKA can strike adults, adolescents and children. However, it appears to be more severe when it occurs in children and adolescents. Among this group, the youngest who are no more than 5 years of age, are the hardest hit. In those with T1D, up to 40% of newly diagnosed children may experience DKA and many, unfortunately, experience it more than once. It remains the leading cause of disease and death in children who suffer from diabetes. Moreover, unlike adult sufferers, those children with DKA who die usually do so from cerebral edema or brain swelling.[4]

Moreover, there is a geographic component to the disease. Frequency of onset varies widely by area. There is also a socio-economic component. DKA is more prominent among those who have poor access to medical care.

What are the Symptoms of DKA?

The onset of DKA presents certain symptoms. Some are specific while others could be attributable to other health issues. Among the most common are:

  • Kussmaul’s respiration –deep and rapid labored breathing[5]
  • Dry skin
  • Dry mouth
  • Dehydration
  • Breath that is fruity smelling
  • Vomiting or nausea (in about 50 to 80 percent of cases)
  • Stomach pain
  • Flushed face

Other potential symptoms may consist of:

  • Abdominal pain – in about 30 percent
  • Breathing difficulty – usually when lying down
  • Polyphagia – increased appetite or constant hunger
  • Fatigue
  • Loss of some degree of consciousness
  • Senses that become dull
  • Polyuria (Frequent urination)
  • Polydipsia – excessive thirst that lasts for a day or more
  • Headache
  • Muscle stiffness
  • Shortness of breath

What is the Treatment for DKA?

The treatment for DKA will vary and a lot depends on how far the DKA has progressed. It should always be treated at the hospital so the diabetic can be closely monitored. When a patient arrives in the hospital, the person is frequently in a coma. They are also severely dehydrated. As a result treatment approaches address dehydration by introducing fluids intravenously. The IV drip will include saline and insulin to lower blood glucose levels.  Usually, additional electrolytes will be added to the IV such as potassium.

If there is a cerebral edema, doctors will also give mannitol or hypertonic saline, repeating the application if there is no response after the first treatment. It may be necessary to start treatment for possible cerebral edema as well as performing tests to rule out any other potential issues such as thrombosis or hemorrhage.[6]

How to Prevent DKA   

Once the patient is feeling better, the diabetic needs to examine the circumstances surrounding the medical problem. The question that is asked is: What provoked it? In other words, did DKA result from:

  1. An unrecognized need for more insulin?
  2. Not knowing the child or adult was diabetic?
  3. A failure to give enough or any insulin?
  4. Carelessness?
  5. The lack of money to take care of the problem?
  6. Psychological reasons?
  7. An adolescent attempt to lose excessive weight?

At this point in time, family and friends should not be judgmental, though AKA can be a frightening event. If required, education or finding financial aid or other types of support to insure the diabetic can effectively manage the diabetes is most important.

If you develop blood glucose levels that reach 240 mg/dl or higher, then you might consider using home urine tests to regularly check ketone levels. The kits use reagent strips you simply first dip in urine, and then you match the color change on the strip to a chart.

You can also purchase a blood glucose meter that has a ketone meter. The combination meter is designed for home use and is very effective since it measures blood levels.

Conclusion

DKA is a complication of diabetes. It occurs most frequently in people with type 1 diabetes, but can occur in anyone with diabetes. Children and adolescents suffer more at its first onset and are at higher risk of cerebral edema than adults.  This is a serious complication that should be prevented as much as possible.

References

[1] Masharani, U (2008). Diabetes DeMYSTiFieD. New York: McGraw Hill.

[2] Guyton, AC; and Hall, JE (2011). Textbook of Medical Physiology, 12th ed. Philadelphia: Saunders.

[3] Warshaw, HS; and Pape, J (2009). Real-Life Guide To Diabetes. Alexandria, VA: ADA.

[4] Steel, S; and Tibby, SM (2009). “Paediatric Diabetic Ketoacidosis.” Continuing Education in Anaesthesia Critical Care Pain, 9 (6): 194-199.

[5] Trachtenbarg, DE (2005). “Diabetic Ketoacidosis.” American Family Physician, 71(9):1705-1714.

[6] Wolfsdorf, J; Craig, ME; Daneman, D; Dunger, D; Edge, J; Lee, W; Rosenbloom, A; Sperling, M; and Hanas, R (2009). “Diabetic Ketoacidosis in Children and Adolescents with Diabetes.” Pediatric Diabetes, 10 (Supplement s12): 118–133.

This article was originally published July 12, 2012 and last revision and update of it was 9/10/2015.