Diabetic ketoacidosis

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.

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Fig. 1: The history of DKA.
Fig. 2: Pathogenesis of DKA.
Fig. 3: Symptoms and signs of DKA.

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Contributions

Introduction (G.E.U., N.S.G., K.K.D., E.C.); Epidemiology (G.E.U., N.S.G., K.K.D., E.C.); Mechanisms/pathophysiology (G.E.U., N.S.G., K.K.D., E.C.); Diagnosis, screening and prevention (G.E.U., N.S.G., K.K.D., E.C.); Management (G.E.U., N.S.G., K.K.D., E.C.); Quality of life (N.S.G.); Outlook (N.S.G, E.C.); Overview of Primer (G.E.U.). All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole and have given their approval for this version to be published.

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Correspondence to Guillermo E. Umpierrez.

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Competing interests

K.K.D. is an employee of the UK National Health Service. N.S.G. has grants from American Diabetes Association (ADA, 1-17-IBS-186) and from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK, U34DK123894). E.C. is partly funded by Fondo Nacional de Ciencia y Tecnología (FONDECYT) grant no. 1170895 from the Government of Chile. G.E.U. is partly supported by research grants from the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under Award Number UL1TR002378 from the Clinical and Translational Science Award program and an NIH grant U30, P30DK11102, and has received research grant support to Emory University for investigator-initiated studies from Dexcom, Novo Nordisk and Sanofi.

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Glossary

Circulatory volume depletion

A reduction in intravascular and/or extracellular fluid volume, such that there may be an inability to adequately perfuse tissue.

BMI z-score

Also known as the BMI standard deviation score. The z-score is a measure of a child’s relative weight adjusted for age and gender.

pKa

The negative base-10 logarithm of the acid dissociation constant (Ka) of a solution. The lower the pKa, the stronger the acid.

Buffering

The ability of molecules in the circulation to stabilize the acid–base balance in an attempt to maintain the pH.

Glomerular filtration rate

An estimate of how much blood passes through the renal glomeruli every minute, which is often calculated from serum creatinine levels, age, sex and body weight.

Pre-renal failure

The loss of kidney function as a result of poor renal or glomerular perfusion, for example, due to haemorrhage, cardiac failure or hypovolaemia.

Hypertonicity

A state in which the circulating extracellular fluid has a higher osmotic pressure than the pressure that would be observed in a healthy individual.

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Dhatariya, K.K., Glaser, N.S., Codner, E. et al. Diabetic ketoacidosis. Nat Rev Dis Primers 6, 40 (2020). https://doi.org/10.1038/s41572-020-0165-1

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