Diabetic Ketoacidosis | Causes, Symptoms, Treatment & Complications

Reviewed by: Steven Chessler, M.D., Ph.D. 5/18.

Diabetic ketoacidosis is a life-threatening complication that affects people with diabetes. DKA can happen to anyone with diabetes, though it’s much more common in people with type 1 diabetes.

In addition to allowing cells to use glucose, insulin also helps to control how fat is broken down and used for energy. A lack of insulin can lead to increased fat breakdown which, in turn, causes the liver to produce chemicals called ketones.

The buildup of ketones makes the blood more acidic. When the blood ketone level gets too high, a condition develops called diabetic ketoacidosis (DKA).

In this article, we’ll explore the causes, symptoms, treatment options, and complications of this life-threatening condition.

Causes of Diabetic Ketoacidosis

DKA results from inadequate insulin levels that cause the fat cells to burn for energy. Under these conditions, ketones are released into the blood by the liver. In people with diabetes, an underlying problem often triggers the onset of DKA.

The following problems or conditions may contribute to DKA:

An illness where the body produces higher levels of stress hormones (illnesses like pneumonia or a urinary tract infection have a counter-effect on insulin)
Not sufficient insulin due to missed doses or more requirements
Alcohol or drug abuse
Less food intake – caused by sickness, fasting, or an eating disorders (bulimia, for example, increases the risk for DKA)
Medications like corticosteroids and diuretics
Pregnancy
Heart attack

Symptoms of Diabetic Ketoacidosis

Symptoms of DKA typically evolve over a period of 24 hours. Some symptoms to be aware of include the following:

Nausea and vomiting
Frequent urination
Excessive thirst
Abdominal pain
Fatigue and confusion
Fruity-scented breath
Difficulty breathing
Low blood pressure

Check your blood glucose levels if you develop these symptoms. If your blood glucose levels are above 240mg/dl (13.3mmol/L), check for ketone levels using a blood or urine ketone testing kit.

Guidelines to Consider When Taking a Blood Ketone Test

Level of ketones in the range of 0.6-1.5mmol/L: You are at a slightly increased risk of developing DKA. A retest should be done in a couple of hours.
Level of ketones in the range of 1.6 – 2.9mmol/L: You are at moderate risk of DKA and should contact a physician.
Level of ketones at or above 3mmol/L: You are at a very high risk of DKA and you should get medical help immediately.

Basic Guideline To Consider When Taking A Urine Ketone Test

If the urine ketone levels show a result of more than 2+, moderate amounts or more, there is a high chance you have DKA and should seek medical help. If there are small or trace amounts, you should retest in a few hours.

If you find that your blood glucose levels and blood/urine ketone levels are high, please contact your doctor. Your doctor may recommend that you visit the closest medical/emergency care facility.

Steps to Bring Down Ketone Levels in Your Body

Drink excess water to flush out ketones from your body.
Keep testing your blood sugar every 3-4 hours and ensure the correct use of insulin
Avoid exercising until your blood glucose and ketone levels drop to normal

Treatment of Diabetic Ketoacidosis

The primary aim of treating DKA is to replace the lost fluids and electrolytes in your body. Here are the most common ways that DKA is treated in the hospital:

Fluid replacement:

The amount of fluid replenishment depends on the degree of dehydration. If dehydration is severe, then rapid infusion of saline is often recommended. If DKA is moderate, then saline is generally infused at a slower rate. A mild case of DKA may be treated with oral rehydration.

Insulin therapy:

Insulin is generally given through IV in the hospital, often at a rate of 0.1unit/kg/hr. When your blood glucose levels fall below 240mg/dl, IV insulin is typically stopped. Potassium (K⁺) levels should be maintained at or above 3.3mmol/L as insulin lowers the amount of this mineral in the blood. In addition to this treatment, your heart rate should be monitored constantly.

Electrolyte replacement:

Insulin and rehydration therapy lowers the level of blood electrolytes, hence they need to be replenished either through IV or oral rehydration. Before leaving the hospital, discuss the steps to prevent DKA with your doctor

What your doctor will recommend

Monitor your blood sugar at least 3-4 times a day or more during times of illness or stress.
Follow your insulin treatment plan.
Take extra care when you are sick and follow the sick day steps discussed with your doctor.
Check your ketone level.
Keep your diabetes in check by avoiding the potential causes of DKA

Complications of Diabetic Ketoacidosis

Although the early signs and symptoms of DKA can often be treated through self-care measures or a trip to the hospital, there are some cases in which other complications may develop. Some of these complications are listed below:

Hyperkalemia and hypokalemia (electrolyte disorders)– Severe increases and decreases in the K⁺ levels during DKA occurrence and treatment can be life-threatening. Therefore, careful monitoring of K⁺ is essential. Severe dehydration and lack of insulin contribute to increased blood levels of K⁺. If the increase is above 5.5 mmol/L, its infusion along with saline is discouraged. Treatment with fluids and insulin leads to a decrease in the K⁺. An important part of the treatment of DKA is ensuring that K⁺ levels are monitored and maintained in a safe range.
Hypoglycemia (low blood sugar) – This complication occurs when blood glucose levels fall too low as ketoacidosis is corrected through treatment. To prevent hypoglycemia, IV glucose can be given when blood sugar levels fall below a predetermined level (e.g., 11 or 14 mmol/L).
Cerebral Edema (swelling of the brain caused by excess fluid) – It is the most dangerous complication of DKA, occurring sub-clinically both before and after treatment. Its cause is unknown. Cerebral hypoperfusion (insufficient blood flow to the brain, which cuts off oxygen supply) with subsequent reperfusion are amongst the processes that may contribute. This critical, life-threatening complication is more common in children than adults.
Pulmonary edema (excess fluid in the lungs) – A rare complication associated with the treatment of DKA. Elderly patients with impaired cardiac function are at a greater risk.

You’ve learned about the causes, symptoms, treatments, and possible complications of DKA. Learn more from an expert by reading the next article in this series: Expert Talk: Eight Things You Should Know About Diabetic Ketoacidosis.

—

Steven Chessler, M.D., Ph.D., is an associate professor and physician-scientist in the Department of Medicine, Division of Endocrinology, at the UC Irvine School of Medicine. He treats patients with diabetes and a variety of other endocrine disorders and, in the laboratory, carries out diabetes- and pancreatic-islet-related research.

Sources:

1. “What is Diabetes? NIDDK.” Online. Accessed: 23-Jan-2018: https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes.

2. “DKA (Ketoacidosis) & Ketones: American Diabetes Association®.”Accessed: 23, Jan-2018: http://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.html?referrer=https://www.google.com/.

3. “Diabetic ketoacidosis, NHS.UK. Accessed: 24, Jan. 2018: https://www.nhs.uk/conditions/diabetic-ketoacidosis.

4. “Diabetic ketoacidosis, “Symptoms and causes” Mayo Clinic.” Accessed: 24-Jan-2018: https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551.

5. G. E. Umpierrez, D. Smiley, and A. E. Kitabchi, “Narrative review: ketosis-prone type 2 diabetes mellitus.,” Ann. Intern. Med., vol. 144, no. 5, pp. 350–7, Mar. 2006.

6. M. S. Eledrisi, M. S. Ashanti, M. F. Shah, and N. Jaha, “Overview of the diagnosis and management of diabetic ketoacidosis.,” Am. J. Med. Sci., vol. 331, no. 5, pp. 243–51, May 2006.