Differentiating Diabetic ketoacidosis from other diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

Diabetic ketoacidosis (DKA) must be differentiated from other conditions presenting with hyperglycemia, ketosis and metabolic acidosis. The differentials include diabetes mellitus, non-ketotic hyperosmolar state, impaired glucose tolerance, ketotic hypoglycemia, alcoholic ketosis, starvation ketosis, lactic acidosis, salicylic acid ingestion, uremic acidosis and drug-induced acidosis. All these conditions may be differentiated on the basis of history findings, clinical features and laboratory abnormalities.

Differentiating Diabetic Ketoacidosis From Other Diseases

Diabetic ketoacidosis must be differentiated from other diseases causing the following conditions:[1][2][3][4][5][6][7][8]

Schematic showing DKA as a confluence of hyperglycemia, ketosis and acidosis
Characteristic Common to DKA Condition History Findings Clinical Features Lab abnormalities
Hyperglycemia Diabetes mellitus
Non-ketotic hyperosmolar state
Impaired glucose tolerance
Ketosis Alcoholic ketosis
Starvation ketosis
Metabolic acidosis Lactic acidosis
Salicylic acid ingestion
Uremic acidosis
Drug-induced acidosis

Differentiating Diabetic Ketoacidosis from Hyperosmolar Hyperglycemia state

Parameters Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic state (HHS)
Plasma glucose
  • > 250 mg/dl
  • > 600 mg/dl
Serum osmolality
  • Variable
  • > 320 mOsm/kg
Plasma and urine ketones
  • Positive
  • None or trace
Serum bicarbonate
  • < 18 mEq/L
  • > 15 mEq/ L
Arterial ph
  • < 7.30
  • > 7.30
Anion gap
  • > 12
  • < 12

Differential diagnosis of increased anion gap metabolic acidosis

 
 
 
 
 
 
 
 
anion gap metabolic acidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lactate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lactic acidosis
 
 
 
 
 
 
 
 
 
 
 
Check for hyperglycemia and ketonuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Present
 
 
 
 
 
 
 
 
 
 
 
 
 
Not Present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diabetic ketoacidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
BUN, ↑ creatinine and history of hemodyalysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uremic acidosis
 
 
 
 
 
 
 
 
 
 
 
Physical findings include odor of alcohol
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ethanol level in serum or expired air
 
 
 
 
 
 
 
 
 
 
 
 
 
Auditory symptoms present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ethanol overdose
 
 
 
 
 
 
 
 
 
 
 
 
 
Salicylic acid overdose

References

  1. "Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician".
  2. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). "Hyperglycemic crises in adult patients with diabetes". Diabetes Care. 32 (7): 1335–43. doi:10.2337/dc09-9032. PMC 2699725. PMID 19564476.
  3. Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, Beauregard H, Ekoé JM, Fournier H, Havrankova J (2003). "Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state". CMAJ. 168 (7): 859–66. PMC 151994. PMID 12668546.
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  8. Brinkmann B, Fechner G, Karger B, DuChesne A (1998). "Ketoacidosis and lactic acidosis--frequent causes of death in chronic alcoholics?". Int. J. Legal Med. 111 (3): 115–9. PMID 9587792.
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  10. Kraut JA, Nagami GT (2013). "The serum anion gap in the evaluation of acid-base disorders: what are its limitations and can its effectiveness be improved?". Clin J Am Soc Nephrol. 8 (11): 2018–24. doi:10.2215/CJN.04040413. PMC 3817910. PMID 23833313.
  11. Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW (2013). "Etiology and therapeutic approach to elevated lactate levels". Mayo Clin. Proc. 88 (10): 1127–40. doi:10.1016/j.mayocp.2013.06.012. PMC 3975915. PMID 24079682.
  12. Abuelo JG, Shemin D, Chazan JA (1992). "Serum creatinine concentration at the onset of uremia: higher levels in black males". Clin. Nephrol. 37 (6): 303–7. PMID 1638782.
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