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What Leads To Diabetic Ketoacidosis?

What Causes Diabetic Ketoacidosis?

What Causes Diabetic Ketoacidosis?

As a type 1 diabetic I am quite familiar (unfortunately) with the signs and symptoms of diabetic ketoacidosis. Diabetic ketoacidosis (DKA) results from associated with too little insulin (and usually high blood sugars as well) which leads to the product of organic acids called ketones. Diabetic ketoacidosis is associated with significant disturbances of the body’s chemistry, which resolve with proper therapy. (And let’s clear up early that DKA and nutritional ketosis experienced in low-carb diets are two extremely different things…but more on that in a different article!) Diabetic ketoacidosis usually occurs in people with type 1 diabetes mellitus, but diabetic ketoacidosis can develop in any person with diabetes. Since type 1 diabetes typically starts before age 25 years, diabetic ketoacidosis is most common in this age group, but it may occur at any age. Males and females are equally affected. What Causes Ketoacidosis? People with type 1 diabetes do not have enough insulin, a hormone the body uses to break down sugar (glucose) in the blood for energy. When glucose is not available, fat is broken down instead. As fats are broken down, acids called ketones build up in the blood and urine. In high levels, ketones are poisonous. This condition is known as ketoacidosis. Blood glucose levels rise (usually higher than 300 mg/dL) because the liver makes glucose to try to combat the problem. However, the cells cannot pull in that glucose without insulin. Diabetic ketoacidosis is often the first sign of type 1 diabetes in people who do not yet have other symptoms. It can also occur in someone who has already been diagnosed with type 1 diabetes. Infection, injury, a serious illness, missing doses of insulin, or surgery can lead to diabetic ketoacidosis in people with type Continue reading >>

Causes And Risk Factors Of Diabetic Ketoacidosis

Causes And Risk Factors Of Diabetic Ketoacidosis

Diabetic ketoacidosis is serious complication of diabetes. This problem occurs when there is low insulin level in blood, that lead to inability of body to use sugar/glucose as energy source. This in turn leads to utilization of fats as energy and breakdown of fats for energy. Breakdown of fats lead to accumulation acid (by product of fat metabolism) known as ketones (these are acidic substances), which makes blood acidic and lead to systemic acidosis and in case of diabetes it is called diabetic ketoacidosis. Excess ketones in blood spill over to urine and it can be detected in urine using simple test kit to detect ketones in urine. Hence, the main cause of diabetic ketoacidosis is low level of insulin in blood as is the case in type-1 diabetes where the patient is unable to produce any insulin because of lack of insulin producing beta cells in pancreas. However, diabetic ketoacidosis can also occur among patients with type-2 diabetes, who are receiving insulin for blood glucose control (because these patients are unable to produce adequate insulin even by using oral hypoglycemic drugs), if they miss one or more doses of insulin or if they receive less than required quantity of insulin (under-treatment). Diabetic ketoacidosis is common among patients of type-1 diabetes. However, type-2 diabetes patients can also develop diabetic ketoacidosis, who are receiving insulin, especially when they miss a dose or two. Diabetic ketoacidosis may be triggered by various factors such as, Illness or infection: an illness or infection may trigger diabetic ketoacidosis. Illness lead to increased requirement of insulin and if the patient receives usual dose of insulin during illness or infection this may not be sufficient to control blood glucose level. There may be increase in blood gl Continue reading >>

Diabetic Ketoacidosis And Hyperglycemic Hyperosmolar Syndrome

Diabetic Ketoacidosis And Hyperglycemic Hyperosmolar Syndrome

In Brief Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are two acute complications of diabetes that can result in increased morbidity and mortality if not efficiently and effectively treated. Mortality rates are 2–5% for DKA and 15% for HHS, and mortality is usually a consequence of the underlying precipitating cause(s) rather than a result of the metabolic changes of hyperglycemia. Effective standardized treatment protocols, as well as prompt identification and treatment of the precipitating cause, are important factors affecting outcome. The two most common life-threatening complications of diabetes mellitus include diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS). Although there are important differences in their pathogenesis, the basic underlying mechanism for both disorders is a reduction in the net effective concentration of circulating insulin coupled with a concomitant elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). These hyperglycemic emergencies continue to be important causes of morbidity and mortality among patients with diabetes. DKA is reported to be responsible for more than 100,000 hospital admissions per year in the United States1 and accounts for 4–9% of all hospital discharge summaries among patients with diabetes.1 The incidence of HHS is lower than DKA and accounts for <1% of all primary diabetic admissions.1 Most patients with DKA have type 1 diabetes; however, patients with type 2 diabetes are also at risk during the catabolic stress of acute illness.2 Contrary to popular belief, DKA is more common in adults than in children.1 In community-based studies, more than 40% of African-American patients with DKA were >40 years of age and more than 2 Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic acidosis is a life-threatening condition that can occur in people with type 1 diabetes. Less commonly, it can also occur with type 2 diabetes. Term watch Ketones: breakdown products from the use of fat stores for energy. Ketoacidosis: another name for diabetic acidosis. It happens when a lack of insulin leads to: Diabetic acidosis requires immediate hospitalisation for urgent treatment with fluids and intravenous insulin. It can usually be avoided through proper treatment of Type 1 diabetes. However, ketoacidosis can also occur with well-controlled diabetes if you get a severe infection or other serious illness, such as a heart attack or stroke, which can cause vomiting and resistance to the normal dose of injected insulin. What causes diabetic acidosis? The condition is caused by a lack of insulin, most commonly when doses are missed. While insulin's main function is to lower the blood sugar level, it also reduces the burning of body fat. If the insulin level drops significantly, the body will start burning fat uncontrollably while blood sugar levels rise. Glucose will then begin to show up in your urine, along with ketone bodies from fat breakdown that turn the body acidic. The body attempts to reduce the level of acid by increasing the rate and depth of breathing. This blows off carbon dioxide in the breath, which tends to correct the acidosis temporarily (known as acidotic breathing). At the same time, the high secretion of glucose into the urine causes large quantities of water and salts to be lost, putting the body at serious risk of dehydration. Eventually, over-breathing becomes inadequate to control the acidosis. What are the symptoms? Since diabetic acidosis is most often linked with high blood sugar levels, symptoms are the same as those for diabetes Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic Ketoacidosis Definition Diabetic ketoacidosis is a dangerous complication of diabetes mellitus in which the chemical balance of the body becomes far too acidic. Description Diabetic ketoacidosis (DKA) always results from a severe insulin deficiency. Insulin is the hormone secreted by the body to lower the blood sugar levels when they become too high. Diabetes mellitus is the disease resulting from the inability of the body to produce or respond properly to insulin, required by the body to convert glucose to energy. In childhood diabetes, DKA complications represent the leading cause of death, mostly due to the accumulation of abnormally large amounts of fluid in the brain (cerebral edema). DKA combines three major features: hyperglycemia, meaning excessively high blood sugar kevels; hyperketonemia, meaning an overproduction of ketones by the body; and acidosis, meaning that the blood has become too acidic. Insulin deficiency is responsible for all three conditions: the body glucose goes largely unused since most cells are unable to transport glucose into the cell without the presence of insulin; this condition makes the body use stored fat as an alternative source instead of the unavailable glucose for energy, a process that produces acidic ketones, which build up because they require insulin to be broken down. The presence of excess ketones in the bloodstream in turn causes the blood to become more acidic than the body tissues, which creates a toxic condition. Causes and symptoms DKA is most commonly seen in individuals with type I diabetes, under 19 years of age and is usually caused by the interruption of their insulin treatment or by acute infection or trauma. A small number of people with type II diabetes also experience ketoacidosis, but this is rare give Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Tweet Diabetic ketoacidosis (DKA) is a dangerous complication faced by people with diabetes which happens when the body starts running out of insulin. DKA is most commonly associated with type 1 diabetes, however, people with type 2 diabetes that produce very little of their own insulin may also be affected. Ketoacidosis is a serious short term complication which can result in coma or even death if it is not treated quickly. Read about Diabetes and Ketones What is diabetic ketoacidosis? DKA occurs when the body has insufficient insulin to allow enough glucose to enter cells, and so the body switches to burning fatty acids and producing acidic ketone bodies. A high level of ketone bodies in the blood can cause particularly severe illness. Symptoms of DKA Diabetic ketoacidosis may itself be the symptom of undiagnosed type 1 diabetes. Typical symptoms of diabetic ketoacidosis include: Vomiting Dehydration An unusual smell on the breath –sometimes compared to the smell of pear drops Deep laboured breathing (called kussmaul breathing) or hyperventilation Rapid heartbeat Confusion and disorientation Symptoms of diabetic ketoacidosis usually evolve over a 24 hour period if blood glucose levels become and remain too high (hyperglycemia). Causes and risk factors for diabetic ketoacidosis As noted above, DKA is caused by the body having too little insulin to allow cells to take in glucose for energy. This may happen for a number of reasons including: Having blood glucose levels consistently over 15 mmol/l Missing insulin injections If a fault has developed in your insulin pen or insulin pump As a result of illness or infections High or prolonged levels of stress Excessive alcohol consumption DKA may also occur prior to a diagnosis of type 1 diabetes. Ketoacidosis can occasional Continue reading >>

Diabetic Ketoacidosis: Causes – Treatment

Diabetic Ketoacidosis: Causes – Treatment

Diabetic Ketoacidosis (DKA) is a life threatening complication of diabetes which occurs when the cells in the body are not able to acquire sufficient amount of glucose required for energy, due to insulin deficiency. The body, to compensate for this lack of gulcose, in turn, begins to break down muscles and fat for energy. This leads to production of ketones or fatty acids which enters the bloodstream, creating chemical imbalance known as diabetic ketoacidosis. DKA can occur in people suffering with either type 1 or type 2 diabetes but it is more common in type 1 diabetes. There are chances that DKA may even occur if you are at a risk for diabetes and have not yet been formally diagnosed as diabetic. Males and females are equally affected by DKA. DKA is a medical emergency, the moment this complication is suspected; you need to immediately contact your physician. This complication can lead to diabetic coma or even death. Risk Factors Suffer with Type 1 diabetes. Frequently miss your insulin doses. Are under the age of 19. Have high temperature. Have stress or are exposed to some form of trauma (physical or emotional). Have had a stroke or heart attack. Are undergoing severe stress. Smoke or drink alcohol. Causes DKA can be generally triggered by the following causative factors Insufficient production of insulin. Severe infection or other illness. Severe dehydration. Missed insulin treatment. Medications such as corticosteroids and few diuretics. Symptoms DKA develops very rapidly, sometimes even within 24 hours. Symptoms experienced in diabetic ketoacidosis are as follows Increased thirst. Increased frequency of urination. Fatigue. Appetite reduced. Confusion. Vomiting. Pain in abdomen. Increased heart rate. Decreased blood pressure. Dry mouth. Dry skin. Fruity odor in b Continue reading >>

Management Of Diabetic Ketoacidosis In Children And Adolescents

Management Of Diabetic Ketoacidosis In Children And Adolescents

Objectives After completing this article, readers should be able to: Describe the typical presentation of diabetic ketoacidosis in children. Discuss the treatment of diabetic ketoacidosis. Explain the potential complications of diabetic ketoacidosis that can occur during treatment. Introduction Diabetic ketoacidosis (DKA) represents a profound insulin-deficient state characterized by hyperglycemia (>200 mg/dL [11.1 mmol/L]) and acidosis (serum pH <7.3, bicarbonate <15 mEq/L [15 mmol/L]), along with evidence of an accumulation of ketoacids in the blood (measurable serum or urine ketones, increased anion gap). Dehydration, electrolyte loss, and hyperosmolarity contribute to the presentation and potential complications. DKA is the most common cause of death in children who have type 1 diabetes. Therefore, the best treatment of DKA is prevention through early recognition and diagnosis of diabetes in a child who has polydipsia and polyuria and through careful attention to the treatment of children who have known diabetes, particularly during illnesses. Presentation Patients who have DKA generally present with nausea and vomiting. In individuals who have no previous diagnosis of diabetes mellitus, a preceding history of polyuria, polydipsia, and weight loss usually can be elicited. With significant ketosis, patients may have a fruity breath. As the DKA becomes more severe, patients develop lethargy due to the acidosis and hyperosmolarity; in severe DKA, they may present with coma. Acidosis and ketosis cause an ileus that can lead to abdominal pain severe enough to raise concern for an acutely inflamed abdomen, and the elevation of the stress hormones epinephrine and cortisol in DKA can lead to an elevation in the white blood cell count, suggesting infection. Thus, leukocytosi Continue reading >>

Diabetic Encephalopathy

Diabetic Encephalopathy

Diabetic encephalopathy is damage to the brain caused by diabetes. A relatively unknown complication, encephalopathy is becoming more widely recognized as more people are diagnosed with type 1 and type 2 diabetes. Diabetic encephalopathy presents itself both mentally and physically. It can induce an altered mental state, cognitive decline, changes in personality, memory lapses, or severe impairment like dementia. The complication can also cause tremors, lack of coordination, and even seizures. Diabetic encephalopathy is largely due to acute hypoglycemia (blood sugar levels are too low) or severe hyperglycemia (blood sugar levels are too high). The condition manifests itself differently between the two major types of diabetes. Type 2 diabetes Encephalopathy in those with type 2 diabetes increases the risk of developing Alzheimer’s disease or other forms of dementia. According to a 2011 study, those with type 2 diabetes were twice as likely to develop Alzheimer’s and 1.75 times more likely to develop other forms of dementia than healthy participants. This increased risk could be due to many different factors brought about from type 2 diabetes. It could be caused by the body’s resistance to insulin, which makes it difficult for the brain to break down amyloid, a protein that forms brain plaques. Brain plaques are abnormal clusters of this protein that block cell-to-cell signaling at the synapses—a symptom infamous for contributing to the development of Alzheimer’s disease. Type 2 diabetic encephalopathy can also be generated from hyperglycemia or the conditions that commonly accompany type 2 diabetes like high blood pressure, obesity, or high cholesterol. Oxidative stress is another provoker of the complication. This stems from an imbalance between reactive oxyge Continue reading >>

Pediatric Diabetic Ketoacidosis

Pediatric Diabetic Ketoacidosis

Practice Essentials Diabetic ketoacidosis, in pediatric and adult cases, is a metabolic derangement caused by the absolute or relative deficiency of the anabolic hormone insulin. Together with the major complication of cerebral edema, it is the most important cause of mortality and severe morbidity in children with diabetes. Signs and symptoms Symptoms of acidosis and dehydration include the following: Symptoms of hyperglycemia, a consequence of insulin deficiency, include the following: Patients with diabetic ketoacidosis may also have the following signs and symptoms: Cerebral edema Most cases of cerebral edema occur 4-12 hours after initiation of treatment. Diagnostic criteria of cerebral edema include the following: Major criteria include the following: Minor criteria include the following: See Clinical Presentation for more detail. Laboratory studies The following lab studies are indicated in patients with diabetic ketoacidosis: Imaging studies Head computed tomography (CT) scanning - If coma is present or develops Chest radiography - If clinically indicated Electrocardiography Electrocardiography (ECG) is a useful adjunct to monitor potassium status. Characteristic changes appear with extremes of potassium status. See the images below. Consciousness Check the patient’s consciousness level hourly for up to 12 hours, especially in a young child with a first presentation of diabetes. The Glasgow coma scale is recommended for this purpose. See Workup for more detail. Management Replacement of the following is essential in the treatment of diabetic ketoacidosis: Insulin - Continuous, low-dose, intravenous (IV) insulin infusion is generally considered the safest and most effective insulin delivery method for diabetic ketoacidosis Potassium - After initial resuscitatio Continue reading >>

Hyperkalaemia In Diabetic Ketoacidosis

Hyperkalaemia In Diabetic Ketoacidosis

Dear Editor, I have a brief comment on the informative ‘Lesson of the week’ by Moulik and colleagues, describing an association between hyperkalaemia and an ECG pattern suggesting acute myocardial infarction in a patient with diabetic ketoacidosis (DKA). One of the mechanisms of hyperkalaemia in DKA stated at the beginning of the Discussion is not strictly correct. It is inorganic acids, and not organic acids (including lactic acid), that cause hyperkalaemia as a result of potassium ions leaving cells in ‘exchange’ for hydrogen ion entry (and their intracellular buffering). In DKA, the key mechanism is lack of insulin, which is probably the most important short-term regulator of plasma potassium concentration (through stimulation of the cell ‘sodium’ pump – Na,K-ATPase) and defence against acute hyperkalaemia resulting from our daily intake of potassium (~80 mmol): The extracellular pool of potassium is around 65 mmol and could almost double after a single steak meal (~50 mmol), which is too rapid a change for compensatory renal excretion. In DKA, an additional mechanism is the osmotic shrinkage of cells as a result of the high plasma glucose concentration (and plasma osmolality), which steepens the intracellular to extracellular potassium concentration gradient and thereby causes an increase in potassium ion loss from cells. Of course, these observations do not materially alter the management of DKA, but only serve to emphasise the importance of inulin administration, glucose control and re-salination over the use (though not excluding it in severe metabolic acidosis) of bicarbonate, bearing in mind that such patients have usually become potassium depleted as a consequence of earlier increased renal losses, and therefore risk developing significant hypoka Continue reading >>

Understanding And Treating Diabetic Ketoacidosis

Understanding And Treating Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a serious metabolic disorder that can occur in animals with diabetes mellitus (DM).1,2 Veterinary technicians play an integral role in managing and treating patients with this life-threatening condition. In addition to recognizing the clinical signs of this disorder and evaluating the patient's response to therapy, technicians should understand how this disorder occurs. DM is caused by a relative or absolute lack of insulin production by the pancreatic b-cells or by inactivity or loss of insulin receptors, which are usually found on membranes of skeletal muscle, fat, and liver cells.1,3 In dogs and cats, DM is classified as either insulin-dependent (the body is unable to produce sufficient insulin) or non-insulin-dependent (the body produces insulin, but the tissues in the body are resistant to the insulin).4 Most dogs and cats that develop DKA have an insulin deficiency. Insulin has many functions, including the enhancement of glucose uptake by the cells for energy.1 Without insulin, the cells cannot access glucose, thereby causing them to undergo starvation.2 The unused glucose remains in the circulation, resulting in hyperglycemia. To provide cells with an alternative energy source, the body breaks down adipocytes, releasing free fatty acids (FFAs) into the bloodstream. The liver subsequently converts FFAs to triglycerides and ketone bodies. These ketone bodies (i.e., acetone, acetoacetic acid, b-hydroxybutyric acid) can be used as energy by the tissues when there is a lack of glucose or nutritional intake.1,2 The breakdown of fat, combined with the body's inability to use glucose, causes many pets with diabetes to present with weight loss, despite having a ravenous appetite. If diabetes is undiagnosed or uncontrolled, a series of metab Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

What is Diabetic Ketoacidosis Diabetic ketoacidosis (DKA) is the hallmark of type 1 (insulin-dependent) diabetes mellitus. DKA is an emergency condition caused by a disturbance in your body’s metabolism. Extremely high blood glucose levels, along with a severe lack of insulin, result in the breakdown of body fat for energy and an accumulation of ketones in the blood and urine. Statistics on Diabetic Ketoacidosis Diabetic ketoacidosis can occur in between 16%-80% of children presenting with newly diagnosed diabetes. It remains the most common cause of death for young type 1 diabetes sufferers. Before the discovery of insulin, mortality rates were up to 100%. Today, the mortality has fallen to around 2% due to early identification and treatment. Death is usually caused by cerebral oedema (swelling of the brain). DKA is most common in type 1 diabetes sufferers but may also occur in those with type 2 diabetes mellitus. However, the latter group usually has at least some functioning insulin so suffer from another disorder called hyperosmolar non-ketotic coma (HONK). DKA tends to occur in individuals younger than 19 years, the more brittle of type 1 diabetic patients. However, DKA can affect diabetic patients of any age or sex. Risk Factors for Diabetic Ketoacidosis People with diabetes lack sufficient insulin, a hormone the body uses to metabolise glucose (a simple sugar) for energy. Therefore in diabetic patients glucose is not available as a fuel, so the body turns to fat stores for energy. However when fats are broken down they produce byproducts called ketones which build up in the blood and can be damaging to the body. In particular, accumulated ketones can “spill” over into the urine and make the blood become more acidic than body tissues (ketoacidosis). Blood gl Continue reading >>

Diabetic Ketoacidosis--pathogenesis, Prevention And Therapy.

Diabetic Ketoacidosis--pathogenesis, Prevention And Therapy.

Abstract Diabetic ketoacidosis is the principal cause of hospital admissions for diabetic patients under 20 years of age, and accounts for at least 4000 deaths per annum in the United States. Current mortality rates differ widely throughout the United States, ranging from 0-19 per cent, with an average of 10 per cent. The principal reason for this wide range in the percentage of mortality are the differing criteria for diagnosis and attributing deaths to diabetic ketoacidosis. There are many reported precipitating causes of diabetic ketoacidosis which may be reduced to four common pathways: insulin deficiency, stress hormone excess, dehydration and fasting. Infection is the most common precipitating cause in most reported series of diabetic ketoacidosis, but stress in any form can lead to metabolic decompensation. Omission of insulin is an unusual cause of ketoacidosis, and in approximately one-quarter of patients no cause can be identified. Each of the four common pathways through which these precipitating causes induce diabetic ketoacidosis results in a rise in ketone body and glucose production and/or concentration. Prevention of diabetic ketoacidosis has been underemphasized in the care of the ill diabetic patient. Prevention of metabolic decompensation in the stressed diabetic patient requires a knowledgeable physician and a cooperative patient. Appropriate physician management of insulin and suppression of stress hormones should prevent diabetic ketoacidosis in all patients who can ingest fluid. Recent studies suggest that if the mortality rate from diabetic ketoacidosis is to be significantly reduced, prevention of this complication is mandatory. Appropriate treatment of diabetic ketoacidosis is not difficult if the physician maintains an accurate flow chart and Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Figure 3. Timeline in DKA management. GCS:Glascow Coma Scale, CBC:Complete Blood Counting, ECG:Electrocardiogram, HR:Heart Rate, BP:Blood Pressure, BUN:Blood Urea Nitrogen, Cr: Creatinine, WBC:White Blood Cell, CRP:C-reactive protein, CE:Cerebral edema (adapted from reference 165) Figure 4. A 15 years old male patient firstly diagnosed T1DM with DKA infected by rhino-orbita-cerebral mucormycozis (Picture from the reference [218]) 1. Introduction A chronic autoimmune destruction of the pancreatic beta cells results in decreasing endogenous insulin secretion and the clinical manifestation of type 1 diabetes mellitus (T1DM). The clinical onset of the disease is often acute in children and adolescents and diabetic ketoacidosis (DKA) is present in 20-74% of the patients [1-7]. DKA is a serious condition that requiring immediate intervention. Even with appropriate intervention, DKA is associated with significant morbidity and possible mortality in diabetic patients in the pediatric age group [8]. Young age and female sex have been associated with an increased frequency of DKA [3,9]. The triad of uncontrolled hyperglycemia, metabolic acidosis and increased total body ketone concentration characterizes DKA [10]. In addition to possible acute complications, it may also influence the later outcome of diabetes [11]. 2. Epidemiology Worldwide, an estimated 65 000 children under 15 years old develop T1DM each year, and the global incidence in children continues to increase at a rate of 3% a year [12,13]. The current incidence in the UK is around 26/100 000 per year [14]. Patterson et al. were aimed to establish 15-year incidence trends for childhood T1DM in European centres with EURODIAB study. 29 311 new cases of T1DM were diagnosed in children before their 15th birthday during a 1 Continue reading >>

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