Diabetic Ketoacidosis - Causes, Diagnosis, and Treatment

Introduction:

Diabetes is becoming a worldwide epidemic affecting millions of people around the globe. The metabolic disorder has a high incidence rate that is only expected to rise in the coming years. With the rise of diabetes, the chances of developing its complications also rise. Diabetic ketoacidosis is a severe and potentially life-threatening complication of diabetes. This complication is more common in individuals with type 1 diabetes, but it can develop in individuals with type 2 diabetes as well. During diabetic ketoacidosis, there is a lack of insulin in the body, which leads to a high concentration of sugar in the blood (higher than 250 mg/dL). The body starts rapidly metabolizing fatty acids to produce ketone bodies which eventually increases the acidity of the blood and causes further damage to various organs.

What Is Diabetes?

Diabetes, often known as diabetes mellitus, is a group of metabolic disorders characterized by persistently high levels of sugar in the blood. Fasting blood sugar level above 125 mg/dl, random blood sugar levels above 200 mg/dl, and HbA1c of more than 6.5 % is the biological reference range for blood sugar levels in diabetics. In 2017, a survey was carried out to estimate that about 425 million individuals worldwide suffer from diabetes, which is the eighth biggest cause of death, according to a WHO report. Diabetes is primarily caused by an insufficient synthesis of the hormone insulin by the pancreas or due to the failure of the body cells to respond to insulin. Based on their cause, diabetes mellitus is classified into two types:

1. Diabetes Mellitus (Type 1): Type 1 diabetes, also known as insulin-dependent diabetes or juvenile diabetes, occurs as a result of the loss of beta cells of the pancreatic islets leading to insufficient insulin production by the pancreas. This loss of beta cells of the pancreatic islets is due to the autoimmune response of the body (when the body’s immune system starts attacking healthy cells), and the exact cause of this autoimmune response of the body is unknown. The common age of onset of the disease can be during early childhood, teenage, or adulthood.

2. Diabetes Mellitus (Type 2): It is also known as adult-onset diabetes or non-insulin-dependent diabetes. Type 2 diabetes is a health condition in which the cells of the body fail to respond to the insulin produced by the pancreas. This inability to respond to insulin is termed insulin resistance. Insulin resistance and insulin secretory abnormalities both contribute to type 2 diabetes development. An unhealthy lifestyle, including high body weight, lack of physical activity, and bad eating habits, is the primary cause of this illness. It is usually prevalent in adulthood, but it has also been seen in obese children.

What Is Diabetic Ketoacidosis?

A serious and potentially fatal side effect of diabetes is diabetic ketoacidosis. This complication is more prevalent in individuals with type 1 diabetes mellitus; however, it may occur in type 2 as well as other types of diabetes under certain conditions. Diabetic ketoacidosis occurs when there are too many ketone bodies present in the blood as well as the urine; when fats are broken down in the liver, water-soluble molecules known as ketones are formed. When too many ketone bodies are built up rapidly in the blood, it leads to severe consequences.

What Causes Diabetic Ketoacidosis?

Sugar or carbohydrates are the main sources of energy for the body, and the metabolism of sugar converts food into energy. Insulin is responsible for helping sugar enter into the cells of the body and helps the body in using sugar to generate energy and then store the rest. In case of insulin shortage, the body starts rapidly metabolizing or burning fatty acids to produce energy. This metabolism of fatty acids in the liver leads to the production of acidic ketone bodies. Ketones are produced by the liver when the body metabolizes fat after a long fasting period. The muscles and the heart generally utilize these ketone bodies. When ketones are created too quickly and accumulate in the blood, they can be harmful because they make the blood acidic (leading to ketoacidosis). Several factors may trigger diabetic ketoacidosis in type 1 and type 2 diabetes. These factors include:

• Intercurrent Illness: The development of a new disease occurring during the progression of diabetes may lead to diabetic ketoacidosis. These diseases include pneumonia, a viral infection of the respiratory passage, inflammation of the intestine, urinary tract infection, etc. The sudden illness causes increased production of the hormone cortisol, and this hormone counteracts the effects of insulin, leading to a lack of insulin in the body which subsequently results in diabetic ketoacidosis.

• Improper Insulin Therapy: Inadequate dosage of insulin, missed or irregular insulin therapy, and dysfunctioning insulin device can also lead to diabetic ketoacidosis.

• Drugs: Certain drugs of the Gliflozin class have been associated with the development of diabetic ketoacidosis in rare cases. This drug is used in the treatment of type 2 diabetes mellitus.

• Other Factors: Several other factors that may lead to diabetic ketoacidosis are pregnancy, heart attack, cocaine abuse, physical or emotional trauma, pancreatitis, obesity, etc.

Is Diabetic Ketoacidosis a Common Diabetes Complication?

• Diabetic ketoacidosis occurs in about 4.6 to 8 diabetics per year.

• People with type 1 diabetes are at a higher risk of developing diabetic ketoacidosis as compared to people with type 2 diabetes.

• Diabetic ketoacidosis is responsible for 14% of all diabetes-related hospital admissions and 16% of all diabetes-related fatalities.

• Diabetic ketoacidosis is substantially more common in young children and adolescents with type 1 diabetes than it is in adults.

What Are the Symptoms of Diabetic Ketoacidosis?

The following are some signs and symptoms of diabetic ketoacidosis:

• Excessive thirst or polydipsia.

• Frequent urination or polyuria.

• Increased appetite or polyphagia.

• Nausea and vomiting.

• Abdominal pain.

• Weakness.

• Tiredness or fatigue.

• Difficulty in breathing and increased respiratory rate.

• Confusion.

• Typical fruity smell or a sweet smell of breath.

• Dehydration.

• Dry mouth and dryness of the skin.

• Rapid heartbeat.

• Low blood pressure.

How Is Diabetic Ketoacidosis Diagnosed?

The diagnosis of diabetic ketoacidosis is made with the help of the following tests and examinations:

• A detailed medical and family history of the patients to evaluate the presence of pre-existing diabetes. A thorough clinical examination is also helpful in study-specific symptoms associated with diabetic ketoacidosis.

• Several blood examinations are done, including blood sugar level, ketone level, and blood acidity. A fasting sugar levels level of more than 125 mg/dl and a blood sugar level of more than 140 two hours after a meal suggest diabetes. In addition, random plasma glucose of more than 200 mg/dl also suggests that the person has diabetes. When the levels exceed 250 mg/dL, the risk of developing diabetic ketoacidosis is increased.

• Ketone level testing requires blood and urine samples to be tested for the presence of ketone bodies. A reading lower than 0.6 mmol/L suggests a normal level of ketone bodies, and a level between0.6 to 1.5mmol/L means a slightly increased risk of diabetic ketoacidosis. At the same time, reading between 1.6 to 2.9mmol/L means an increased risk of diabetic ketoacidosis.

• Blood acidity is tested to confirm the diagnosis of diabetic ketoacidosis. Increased levels of ketone bodies in the blood will increase the acidity of the blood, which may have a harmful effect on all the organs of the body. A pH level of 7.25 to 7.3 suggests mild diabetic ketoacidosis, a pH level between 7.0 to 7.24 suggests moderate diabetic ketoacidosis, and a pH level less than 7 suggests severe diabetic ketoacidosis.

• In addition, a few other tests like electrocardiogram (ECG) of the heart, X-ray of the chest, blood electrolyte test, and urinalysis may also be done.

How Is Diabetic Ketoacidosis Treated?

Diabetic ketoacidosis is a critical and life-threatening condition and requires immediate medical treatment. While treating diabetic ketoacidosis, certain things must be kept under consideration; managing fluid loss, correcting hyperglycemia, maintaining electrolyte balance, maintaining acid-base balance, and treatment of the intercurrent illness or infection.

• Fluid Replacement: A large amount of body fluid is lost due to frequent urination, which requires immediate replacement. This fluid replacement may be done orally or intravenously (given through a vein).

• Electrolyte Replacement: Lack of insulin and fluid loss leads to an imbalance in the levels of sodium, potassium, and chloride. This is managed by intravenous administration of electrolytes.

• Insulin Therapy: The cornerstone of diabetic ketoacidosis treatment is insulin replacement which will help compensate for the lack of insulin in the body. Insulin will reverse the effects of diabetic ketoacidosis. Insulin may be given through the vein till the blood sugar level drops below 200 mg/dL.

• Acid-Base Balance: In the case of severe diabetic ketoacidosis, sodium bicarbonate is given to regulate the acid-base balance in the blood. However, quick and early correction of diabetic ketoacidosis with sodium bicarbonate may worsen decreased potassium levels and cause paradoxical cellular acidosis.

• Treatment of Infection or Illness: In case of an infection that might have triggered diabetic ketoacidosis, immediate treatment with antibiotics should be done.

What Are the Possible Complications of Diabetic Ketoacidosis Treatment?

The possible complications of treatment include:

• Extremely low blood sugar levels or hypoglycemia.

• Low potassium levels (occurring due to administration of fluids and insulin).

• Cerebral edema or swelling in the brain may occur when the blood sugar levels are adjusted quickly. This complication is prevalent in children.

Conclusion:

Diabetic ketoacidosis is a serious and potentially life-threatening complication of diabetes, and if not treated on time, it may lead to severe illness or even death. However, if prompt and correct treatment is provided, the condition has an excellent prognosis. Most people affected by diabetic ketoacidosis respond to the treatment within twenty-four hours, but the recovery might take a longer time. Earlier, diabetic ketoacidosis was considered a fatal condition universally, but the risk of death with proper treatment is less than one to five percent.