What is diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is a life-threatening condition caused by a build-up of waste products called ketones in the blood. It occurs in people with diabetes mellitus when they have no, or very low levels of, insulin.

DKA mostly occurs in people with type 1 diabetes, but it can also occur in some people with type 2 diabetes and pregnant women with gestational diabetes

Insulin

A hormone secreted by the pancreas in order to regulate glucose levels in the body's cells, which is used for energy.

Ketones

An acid that is produced by the body during the breakdown of fats for energy. It can be seen in patients with type 1 diabetes mellitus when the body cannot use sugar for energy and breaks down fat instead.

Causes

Glucose is an essential energy source for the body's cells. When food containing carbohydrates is eaten, it is broken down into glucose that travels around the body in the blood, to be absorbed by cells that use it for energy.

Insulin works to help glucose pass into cells. Without insulin, the cells cannot absorb glucose to use for energy. This leads to a series of changes in metabolism that can affect the whole body.

The liver attempts to compensate for the lack of energy in the cells by producing more glucose, leading to increased levels of glucose in the blood, also known as hyperglycaemia.

The body switches to burning its stores of fat instead of glucose to produce energy. This leads to a build-up of acidic waste products called ketones in the blood and urine. This is known as ketoacidosis, and it can cause heart rhythm abnormalities, breathing changes and abdominal pain.

The kidneys try to remove some of the excess glucose and ketones. However, this requires taking large amounts of fluid from the body, which leads to dehydration.

This can cause:

  • Increased concentration of ketones in the blood, worsening the ketoacidosis;
  • Loss of electrolytes such as potassium and salt that are vital for the normal function of the body's cells, and;
  • Very low blood pressure that can lead to shock and failure of vital organs.

Blood pressure

The pressure the blood places on the walls of the arteries, largely mirroring the contraction of the heart, and consisting of two readings. The higher reading is systolic blood pressure, when the heart contracts, and the lower is diastolic blood pressure, when the heart is relaxed.

Carbohydrates

One of the three macronutrients in foods that supply the body with energy. Examples include sugars, starches and cellulose.

Cells

The fundamental unit of life; the simplest living unit that can exist, grow, and reproduce independently. The human body is composed of trillions of cells of many kinds.

Dehydration

The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.

Electrolytes

Substances that form ions when dissolved in water. These include potassium and sodium minerals that are necessary for normal functioning of the body and all its cells.

Glucose

A simple sugar found in many foods (such as fruit) that functions as a major energy source for the body.

Insulin

A hormone secreted by the pancreas in order to regulate glucose levels in the body's cells, which is used for energy.

Kidneys

A pair of organs responsible primarily for regulating the water balance in the body and filtering the blood.

Liver

A large, internal organ of the body, located on the upper right-hand side of the abdomen. The liver has hundreds of distinct functions, including producing bile, regulating the body's metabolism and detoxifying the blood.

Metabolism

The sum of all chemical changes that take place within an organism to maintain growth and development and convert food into energy and building blocks.

Shock

A life-threatening condition in which the organs and other tissues do not receive adequate blood flow.

Abdominal

Relating to the abdomen, the middle portion of the trunk which contains organs such as the intestines, stomach and liver.

Potassium

A water-soluble compound and major mineral that is essential for maintaining contractions of muscles, including the heart.

Ketones

An acid that is produced by the body during the breakdown of fats for energy. It can be seen in patients with type 1 diabetes mellitus when the body cannot use sugar for energy and breaks down fat instead.

Risk factors

For people with type 1 diabetes, factors that can increase the risk of DKA include:

The risks are highest in the period just before diabetes is diagnosed. The symptoms of DKA may be the first sign of type 1 diabetes. Younger people - particularly in their teens - with type 1 diabetes tend to be at greater risk of developing DKA.

DKA is much less common in people with type 2 diabetes, but factors that can increase the risk include:

Pregnant women who have pre-existing diabetes or develop gestational diabetes during pregnancy can also be at risk of developing ketoacidosis.

Insulin

A hormone secreted by the pancreas in order to regulate glucose levels in the body's cells, which is used for energy.

Pancreatitis

Inflammation of the pancreas.

Sepsis

An illness caused by inflammation throughout the body in response to an infection. It can be life-threatening if it leads to septic shock, a dramatic loss of blood pressure.

Stress

The word ‘stress’ can have a variety of meanings, but generally describes the physical and mental responses of the body to a demand placed upon it. Often used to describe conditions where the demand is high or unable to be resolved and creates anxiety and tension.

Bacterial

Relating to bacteria, which are microscopic organisms with DNA, but no definite nucleus. They are capable of causing many diseases in humans.

Bacterial

Relating to bacteria, which are microscopic organisms with DNA, but no definite nucleus.

Signs and symptoms

Symptoms of DKA can develop over the course of hours. They can include:

  • Increased thirst; 
  • Increased frequency of urination;
  • Abdominal pains, which can be severe;
  • Nausea and vomiting;
  • Shortness of breath and rapid breathing;
  • A fruity smell to the breath, similar to the smell of nail polish;
  • Drowsiness and confusion;
  • Flushed cheeks;
  • Headache, and;
  • General weakness and fatigue.

DKA can rapidly cause severe dehydration.

People who self-test their own blood and urine may notice:

  • Higher blood glucose levels, and;
  • Higher ketone levels in the urine.

If you notice signs or symptoms of DKA, it is important to contact your doctor immediately or seek emergency treatment. This is the case even if there has not been a previous diagnosis of diabetes.

Dehydration

The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.

Fatigue

A state of exhaustion and weakness.

Glucose

A simple sugar found in many foods (such as fruit) that functions as a major energy source for the body.

Nausea

A sensation of sickness and unease, typically felt in the stomach, often accompanied by the urge to vomit. Nausea is a common symptom with many possible causes.

Abdominal

Relating to the abdomen, the middle portion of the trunk which contains organs such as the intestines, stomach and liver.

Ketone

An acid that is produced by the body during the breakdown of fats for energy. It can be seen in patients with type 1 diabetes mellitus when the body cannot use sugar for energy and breaks down fat instead.

Methods for diagnosis

Your doctor may ask you about your symptoms, results of any self-testing of blood glucose and ketone levels and any factors that might have triggered DKA.

A physical examination can help to evaluate the severity of symptoms. In particular, your doctor may focus on checking for signs of dehydration.

Blood tests and urine tests are used to detect DKA by measuring the levels of glucose and ketones.

Monitoring blood glucose level using a glucose hand monitor.A hand-held portable glucose measuring device. 

Other tests may be recommended to detect any underlying conditions that may have triggered the DKA and determine if you have any complications.

These can include:

  • Blood tests for electrolyte levels, such as sodium and potassium;
  • Amylase test, which detects an enzyme released by the pancreas when it is inflamed;
  • Arterial blood gas test, which measures levels of oxygen and carbon dioxide in the blood and can measure acidity in the blood;
  • Glycated haemoglobin test, which can help to determine whether diabetes control is an ongoing problem, or whether it was due to a one-off problem with insulin levels;
  • Chest X-ray, and;
  • Electrocardiography (ECG) to check for any heart rhythm abnormalities.

Blood tests

During a blood test, blood can be drawn using a needle or by a finger prick. Your blood can then be analysed to help diagnose and monitor a wide range of health conditions.

Dehydration

The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.

Electrolyte

Substances that form ions when dissolved in water. These include potassium and sodium minerals that are necessary for normal functioning of the body and all its cells.

Glucose

A simple sugar found in many foods (such as fruit) that functions as a major energy source for the body.

Insulin

A hormone secreted by the pancreas in order to regulate glucose levels in the body's cells, which is used for energy.

Pancreas

An organ located behind the stomach that secretes insulin and glucagon into the bloodstream and digestive enzymes into the intestines.

Urine tests

A routine examination of the urine for cells, microbes, or chemicals that can indicate a range of different illnesses.

X-ray

A scan that uses ionising radiation beams to create an image of the body’s internal structures.

Potassium

A water-soluble compound and major mineral that is essential for maintaining contractions of muscles, including the heart.

Glycated haemoglobin test

A test used to measure long-term levels of glucose in the blood, usually in patients with diabetes.

Amylase test

A test that measures a specific pancreatic enzyme, called amylase, usually in the blood or urine. It is commonly used as a marker for pancreatic disorders, such as pancreatitis (an inflamed pancreas).

Ketone

An acid that is produced by the body during the breakdown of fats for energy. It can be seen in patients with type 1 diabetes mellitus when the body cannot use sugar for energy and breaks down fat instead.

Electrocardiography

A test that uses electrodes placed on the chest and limbs to record the electrical impulses causing the contractions of the heart.

Types of treatment

DKA usually requires treatment in a hospital. Treatment aims to:

It is important that this treatment be monitored carefully to make sure that glucose and electrolyte levels are maintained at safe levels, or complications may develop.

Any underlying conditions that may have triggered DKA may also need treatment. If the DKA is a sign of undiagnosed diabetes, your doctor will develop a plan to help you manage your diabetes.

Cells

The fundamental unit of life; the simplest living unit that can exist, grow, and reproduce independently. The human body is composed of trillions of cells of many kinds.

Dehydration

The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.

Electrolytes

Substances that form ions when dissolved in water. These include potassium and sodium minerals that are necessary for normal functioning of the body and all its cells.

Glucose

A simple sugar found in many foods (such as fruit) that functions as a major energy source for the body.

Insulin

A hormone secreted by the pancreas in order to regulate glucose levels in the body's cells, which is used for energy.

Intravenously

Within a vein.

Potential complications

Complications that can occur with treatment of DKA include:

Hypoglycaemia

If insulin causes blood glucose levels to drop too low, this can cause hypoglycaemia, a serious condition that can cause people to lose consciousness.

Hypokalaemia

Replacement of fluids to treat dehydration can lead to potassium levels falling too low, known as hypokalaemia. As potassium is vital for the function of muscles, nerves and the heart, this can be dangerous.

Cerebral oedema

If blood sugar levels change too quickly, it can lead to swelling in the brain (cerebral oedema), particularly in children. In turn, this swelling restricts the flow of oxygen-rich blood to the brain, which can result in the damage or death of brain cells.   

Careful monitoring of blood glucose and electrolyte levels during treatment can help to prevent these complications.

Cells

The fundamental unit of life; the simplest living unit that can exist, grow, and reproduce independently. The human body is composed of trillions of cells of many kinds.

Dehydration

The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.

Electrolyte

Substances that form ions when dissolved in water. These include potassium and sodium minerals that are necessary for normal functioning of the body and all its cells.

Glucose

A simple sugar found in many foods (such as fruit) that functions as a major energy source for the body.

Insulin

A hormone secreted by the pancreas in order to regulate glucose levels in the body's cells, which is used for energy.

Nerves

One or more fibres that transmit signals of sensation and motion between the brain or spinal cord and other parts of the body.

Potassium

A water-soluble compound and major mineral that is essential for maintaining contractions of muscles, including the heart.

Prognosis

With prompt treatment, the prognosis of DKA is generally good. However, every year people still continue to die from diabetic ketoacidosis, often as a result of not seeking treatment early.

Prevention

While DKA cannot always be prevented, by managing diabetes well, you can significantly reduce the risk of it occurring.

Steps you can take include:

  • Regularly monitoring your blood glucose to make sure it stays within healthy levels. Your doctor can advise on how often you may need to check it;
  • Checking your ketone levels if advised to do so by your doctor, and;
  • Taking insulin and/or other diabetes medications as directed by your doctor.

Glucose

A simple sugar found in many foods (such as fruit) that functions as a major energy source for the body.

Insulin

A hormone secreted by the pancreas in order to regulate glucose levels in the body's cells, which is used for energy.

Ketone

An acid that is produced by the body during the breakdown of fats for energy. It can be seen in patients with type 1 diabetes mellitus when the body cannot use sugar for energy and breaks down fat instead.