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{{Diabetic ketoacidosis}}

{{Diabetes}}

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==Overview==
'''Diabetic ketoacidosis''' (DKA) is a life-threatening complication in patients with untreated [[diabetes mellitus]] ([[chronic (medicine)|chronic]] high [[blood sugar]] or [[hyperglycemia]]). Near complete deficiency of [[insulin]] and elevated levels of certain [[stress hormone]]s combine to cause DKA.  DKA is more common among [[type I diabetes|Type I diabetics]], but may also occur in [[type II diabetes|Type II diabetics]] generally when physiologically stressed, such as during an infection.  Patients with new, undiagnosed [[Type I diabetes]] frequently present to hospitals with DKA.   DKA can also occur in a known diabetic who fails to take prescribed insulin. DKA was a major cause of death in Type I diabetics before insulin injections were available; untreated DKA has a high [[mortality rate]].  

==Pathophysiology==
DKA is characterized by [[hyperglycemia]], [[acidosis]], and high levels of circulating [[ketone bodies]].  The [[pathogenesis]] of DKA is mainly due to acidosis.  Excessive production of ketone bodies lowers the [[pH]] of the blood; a blood pH below 6.7 is incompatible with life.  Onset of DKA may be fairly rapid, often within 24 hours.  
A key component of DKA is that there is no or very little circulating [[insulin]] so it occurs mainly (but not exclusively) in type 1 diabetes (because type 1 diabetes is characterized by a lack of insulin production in the pancreas). It is much less common in type 2 diabetes because that is closely related to cell insensitivity to insulin, not shortage or absence of insulin. Some type 2 diabetics have lost their own insulin production and must take external insulin; they have some susceptibility to DKA. 
Although [[glucagon]] plays a role as an [[antagonistic hormone]] to insulin when there are low [[blood glucose]] levels, mainly by stimulating the process of [[glycogenolysis]] in [[hepatocyte]]s (liver cells), insulin is the much more important hormone with more widespread effects throughout the body. Its presence or absence can by itself regulate most of DKA's [[pathology|pathological]] effects; notably, it has a short [[half-life]] in the blood of only a few minutes (typically about six), so little time is needed between cessation of insulin release internally and the reduction of insulin levels in the blood.
Most cells in the body are sensitive to one or more of insulin's effects; the main exception being [[erythrocytes]], [[neuron]]s, hepatocytes, some [[intestine|intestinal]] tissue, and [[beta cell|pancreatic beta-cell]]s which do not require insulin to absorb glucose from the blood. The difference is due to different [[glucose transporter]] (GLUT) proteins. Most cells contain only GLUT-4 proteins which move to the cell surface membrane when stimulated by a second messenger cascade initiated by insulin, thus enabling uptake of glucose. Conversely, when insulin concentrations are low, these transporters dissociate from the cell membrane and so prevent uptake of glucose.

Other effects of insulin include stimulation of the formation of [[glycogen]] from glucose and inhibition of glycogenolysis;  stimulation of [[fatty acid]] (FA) production from stored lipids <!-- animals lack the enxyme machinery to do this -- "synthesis from glucose" --> and inhibition of FA release into the blood; stimulation of FA uptake and storage; inhibition of protein [[catabolism]] and of gluconeogenesis, in which glucose is synthesised (mostly from some amino acid types, released by protein catabolism). A lack of insulin therefore has significant effects, all of which contribute to increasing blood glucose levels, to increased fat metabolism and protein degradation. Fat metabolism is one of the underlying causes of DKA.

===Muscle wasting===
Muscle wasting occurs primarily due to the lack of inhibition of protein catabolism; insulin inhibits the breakdown of proteins and, since muscle tissue is protein, a lack of insulin encourages muscle wasting, releasing amino acids both to produce glucose (by gluconeogenesis) and for the synthesis of ATP via partial respiration of the remaining amino acids.
In those suffering from starvation, blood glucose concentrations are low due to both low consumption of carbohydrates and because most of the glucose available is being used as a source of energy by tissues unable to use most other sources of energy, such as neurons in the brain. Since insulin lowers blood glucose levels, the normal bodily mechanism here is to prevent insulin secretion, thus leading to similar fat and protein catabolic effects as in [[Type I diabetes|type 1 diabetes]]. Thus the muscle wastage visible in those suffering from starvation also occurs in [[Type I diabetes|type 1 diabetics]], normally resulting in weight loss.

===Ketone body production===
Despite possibly high circulating levels of plasma glucose, the liver will act as though the body is starving if insulin levels are low. In [[starvation]] situations, the liver produces another form of fuel: [[ketone bodies]]. [[Ketogenesis]], that is [[fat]] metabolic processing (beginning with [[lipolysis]]), makes ketone bodies as intermediate products in the metabolic sequence as fatty acids (formerly attached to a glycerol backbone in triglycerides) are processed. The ketone bodies beta-hydroxybutyrate and [[acetoacetate]] enter the bloodstream and are usable as fuel for some organs such as the brain, though the brain still requires a substantial proportion of glucose to function. If large quantities of ketone bodies are produced, the metabolic imbalance known as [[ketosis]] may develop, though this condition is not necessarily harmful. The positive charge of ketone bodies causes decreased blood pH. An extreme excess of ketones can cause ketoacidosis. In starvation conditions, the liver also uses the [[glycerol]] produced from triglyceride metabolism to make glucose for the brain, but there is not nearly enough glycerol to meet the body's glucose needs.

===Brain===
Normally, ketone bodies are produced in minuscule quantities, feeding only part of the energy needs of the [[heart]] and brain. In DKA, the body enters a starving state. Eventually, neurons (and so the brain) switch from using glucose as a primary fuel source to using ketone bodies. As a result, the bloodstream is filled with an increasing amount of glucose that it cannot use (as the liver continues [[gluconeogenesis]] and exporting the glucose so made). This significantly increases its [[osmolality]]. At the same time, massive amounts of ketone bodies are produced, which, in addition to increasing the osmolar load of the blood, are [[acid]]ic. As a result, the [[pH]] of the blood begins to move downward towards an acidotic state. The normal pH of human blood is 7.35-7.45, in acidosis the pH dips below 7.35.  Very severe acidosis may be as low as 6.9-7.1.  The acidic shift in the blood is significant because the proteins (i.e. body tissues, enzymes, etc.) in the body will be permanently denatured by a pH that is either too high or too low, thereby leading to widespread tissue damage, organ failure, and eventually death. Glucose begins to spill into the [[urine]] as the proteins responsible for reclaiming it from urine (the SGLT family) reach maximum capacity (the renal threshold for glucose). As glucose is excreted in the urine, it takes a great deal of body water with it, resulting in dehydration.  Dehydration further concentrates the blood and worsens the increased osmolality of the blood.  Severe dehydration forces water out of cells and into the bloodstream to keep vital [[organ (biology)|organs]] perfused.  This shift of intracellular water into the bloodstream occurs at a cost as the cells themselves need the water to complete chemical reactions that allow the cells to function.

==Diagnosis==
===Symptoms===
* [[Sluggish]], [[extreme tiredness]] 
* [[Fruity smell to breath]]/compare to nail polish remover, similar to peardrops
* Extreme [[thirst]], despite large fluid intake
* [[Constant urination]]
* Extreme [[weight-loss]]
* [[Oral Thrush]] may be present, or/ [[yeast infection]]s that fail to go away, this is because the normal fungal/flora present in oral cavity/cervix in women, the balance is upset and bacterial began to feast on the high sugar from urine output/ dry mouth from extreme thirst.
* [[Muscle wasting]]
* [[Agitation]] / [[Irritation]] / [[Aggression]] / [[Confusion]]

====Late symptoms====
At this point, DKA is life-threatening and medical attention should be sought immediately.
* Emesis ([[vomiting]]), although this is not always a sign of late-stage ketoacidosis, and can occur both in early-stage ketoacidosis and in non-ketoacidic hyperglycaemia.
* [[Confusion]]
* [[Abdominal pain]]
* [[Loss of appetite]]
* [[Influenza|Flu]]-like symptoms
* [[Lethargy]] and [[apathy]]
* Extreme [[weakness]]
* [[Kussmaul breathing]] ("air hunger"). Patients breathe more deeply and/or rapidly.
* [[Unconsciousness]] ([[diabetic coma]]) after prolonged DKA. At this stage, speedy medical attention is imperative.

==Complications==
People with diabetic ketoacidosis need close and frequent monitoring for complications. Surprisingly, the most common complications of DKA are related to the treatment:
* [[Hypokalemia]] and often, [[potassium depletion]]
* [[Cerebral edema]] <ref name=mayo>{{cite web | By Mayo Clinic Staff  | title = Diabetic ketoacidosis | publisher=Mayo Foundation for Medical Education and Research | work = Diabetic ketoacidosis | url=http://www.mayoclinic.com/health/diabetic-ketoacidosis/DS00674/DSECTION=7 | year = 2006 | accessdate=2007-06-15}}</ref>
* [[Hyperglycemia]]
* [[Ketoacidemia]]
* Fluid and electrolyte depletion <ref name=AMN>{{cite web | Umesh Masharani, MB, BS, MRCP | title = Diabetic Coma > Diabetic ketoacidosis | publisher=Armenian Medical Network | work = Diabetic ketoacidosis | url=http://www.health.am/db/diabetic-ketoacidosis/ | year = 2006 | accessdate=2007-06-15}}</ref>
* [[Aspiration]]
* Unrecognized [[renal tubular necrosis]]
* [[Pulmonary edema]] <ref name=monitor>{{cite web | title = Diabetic ketoacidosis complications| publisher=The Diabetes Monitor | work = Diabetic ketoacidosis | url=http://www.diabetesmonitor.com/dmemerh/sld033.htm | year = 2007 | accessdate=2007-06-15}}</ref>

==Treatment==
Treatment consists of hydration to lower the [[osmolality]] of the blood, replacement of lost electrolytes, insulin to force glucose and [[potassium]] into the cells, and eventually glucose simultaneously with insulin in order to correct other [[metabolic]] abnormalities, such as lowered blood potassium ([[hypokalemia]]) and elevated ketone levels.  Many patients require admission to a step-down unit or an [[intensive care unit]] (ICU) so that [[vital signs]], urine output, and blood tests can be monitored frequently. Brain [[edema]] is not rare, and so this may suggest intensive monitoring as well. In patients with severe alteration of mental status, [[intubation]] and [[mechanical ventilation]] may be required. Survival is dependent on how badly-deranged the metabolism is at presentation to a [[hospital]], but the process is only occasionally fatal.
DKA occurs more commonly in type 1 diabetes because insulin deficiency is most severe, though it can occur in type 2 diabetes. In about a quarter of young people who develop type 1 diabetes, insulin deficiency and hyperglycemia lead to ketoacidosis before the disease is recognized and treated. This can occur at the onset of type 2 diabetes as well, especially in young people. In a person known to have diabetes and being adequately treated, DKA usually results from omission of [[insulin]], mismanagement of acute [[gastroenteritis]], the flu, or the development of a serious new health problem (e.g., [[bacterial infection]], [[myocardial infarction]]).

Insulin deficiency switches many aspects of metabolic balance in a catabolic direction. The liver becomes a net producer of glucose by way of [[gluconeogenesis]] (from protein) and [[glycogenolysis]] (from glycogen, though this source is usually exhausted within hours). Fat in [[adipose tissue]] is reduced to [[triglycerides]] and fatty acids by [[lipolysis]]. Muscle is degraded to release amino acids for gluconeogenesis. The rise of fatty acid levels is accompanied by increasing levels of ketone bodies ([[acetone]], [[acetoacetate]] and beta-hydroxybutyrate; only one, acetone, is chemically a ketone -- the name is an historical accident). As ketosis worsens, it produces a [[metabolic acidosis]], with [[anorexia]], abdominal distress, and eventually vomiting. The rising level of glucose increases the volume of urine produced by the kidneys (an osmolar [[diuresis]]). The high volume of urination ([[polyuria]]) also produces increased losses of electrolytes, especially [[sodium]], [[potassium]], [[chloride]], [[phosphate]], and [[magnesium]]. Reduced fluid intake from [[vomiting]] combined with amplified urination produce dehydration. As the [[metabolic acidosis]] worsens, it induces obvious [[hyperventilation]] (termed [[Kussmaul breathing|Kussmaul respiration]]). [[Kussmaul breathing | Kussmaul's respirations]] are the body's attempt to remove carbon dioxide from the blood that would otherwise form [[carbonic acid]] and further worsen the ketoacidosis.  See also [[arterial blood gas]].  

On presentation to hospital, patients in DKA are typically suffering dehydration and breathing both fast and deeply. [[Abdominal pain]] is common and may be severe. Consciousness level is typically normal until late in the process, when [[obtundation]] (dulled or reduced level of alertness or consciousness) may progress to [[coma]]. Dehydration can become severe enough to cause shock. Laboratory tests typically show [[hyperglycemia]], [[metabolic acidosis]], normal or elevated potassium, and severe [[ketosis]]. Many other tests can be affected.

At this point the patient is urgently in need of intravenous fluids. The basic principles of DKA treatment are:
* Rapid restoration of adequate circulation and perfusion with [[isotonic]] intravenous fluids 
* Gradual rehydration and restoration of depleted electrolytes (especially sodium and potassium), even if serum levels appear adequate 
* Insulin to reverse ketosis and lower glucose levels 
* Careful monitoring to detect and treat complications

Treatment usually results in full recovery, though death can result from inadequate treatment or a variety of complications, such as cerebral edema (occurs mainly in children).

==References==
{{Reflist}}

{{Endocrine pathology}}

[[Category:Diabetes]]
[[Category:Endocrinology]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]
[[Category:Mature chapter]]


[[es:Cetoacidosis diabética]]
[[ja:糖尿病性ケトアシドーシス]]
[[ko:당뇨병케톤산증]]
[[pl:Kwasica ketonowa]]
[[tr:diabetik ketoasidoz]]
[[vi:Toan xêtôn do đái tháo đường]]

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