Differentiating Diabetic ketoacidosis from other diseases: Difference between revisions
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! align="center" style="background:#4479BA; color: #FFFFFF;" + |Lab abnormalities | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Lab abnormalities | ||
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| rowspan="3" |Hyperglycemia | | rowspan="3" |[[Hyperglycemia]] | ||
|Diabetes mellitus | |[[Diabetes mellitus]] | ||
| | | | ||
* Family history of diabetes | * [[Family history]] of [[diabetes]] | ||
* Obesity (BMI >25 kg/m2) | * [[Obesity]] ([[Body mass index|BMI]] >25 kg/m2) | ||
* Stress | * Stress | ||
* Sedentary lifestyle | * [[Sedentary lifestyle]] | ||
* History of gestational diabetes | * History of [[gestational diabetes]] | ||
* Polycystic ovarian syndrome | * [[Polycystic ovary syndrome|Polycystic ovarian syndrome]] | ||
* Acanthosis nigricans | * [[Acanthosis nigricans]] | ||
* Hypertension (>140/90 mmHg) | * [[Hypertension]] ([[Blood pressure]] >140/90 mmHg) | ||
| | | | ||
* Polyuria | * [[Polyuria]] | ||
* Polydipsia | * [[Polydipsia]] | ||
* Polyphagia | * [[Polyphagia]] | ||
* Weight loss | * [[Weight loss]] | ||
* Central obesity | * [[Central obesity]] | ||
* Autonomic and peripheral neuropathy | * [[Autonomic neuropathy|Autonomic]] and [[peripheral neuropathy]] | ||
* Vascular occlusion secondary to atherosclerosis (Stroke, myocardial infarction) | * Vascular occlusion secondary to [[atherosclerosis]] ([[Stroke]], [[myocardial infarction]]) | ||
* Renal impairment (microalbuminuria leading to renal failure) | * [[Renal impairment]] ([[microalbuminuria]] leading to [[renal failure]]) | ||
* Decreased visual acuity (diabetic | * Decreased [[visual acuity]] ([[diabetic retinopathy]]) | ||
* Increased susceptibility to infections | * Increased susceptibility to [[infections]] | ||
* Charcot's joints | * [[Charcot joint|Charcot's joints]] | ||
| | | | ||
* Hyperglycemia: | * [[Hyperglycemia]]: | ||
** Fasting blood glucose level: >126 mg/dl | ** [[Fasting blood sugar|Fasting blood glucose]] level: >126 mg/dl | ||
** Random blood glucose level: >200 mg/dl | ** Random [[blood]] [[glucose]] level: >200 mg/dl | ||
* HbA1C: >6.5 % | * [[Glycosylated hemoglobin|HbA1C]]: >6.5 % | ||
* Urinanalysis may show: | * [[Urinalysis|Urinanalysis]] may show: | ||
** Proteinuria | ** [[Proteinuria]] | ||
** Glucosuria | ** [[Glucosuria]] | ||
* Positive antibodies:(Type 1 diabetes) | * Positive [[antibodies]]:(Type 1 diabetes) | ||
** Anti-glutamic acid decarboxylase | ** Anti-[[glutamic acid decarboxylase]] | ||
** Anti-islet cell | ** Anti-[[Islets of Langerhans|islet cell]] | ||
** Anti-insulin | ** Anti-[[insulin]] | ||
|- | |- | ||
|Non-ketotic hyperosmolar state | |[[Hyperosmolar hyperglycemic state|Non-ketotic hyperosmolar state]] | ||
| | | | ||
* Elderly with type 2 diabetes mellitus | * Elderly with [[type 2 diabetes mellitus]] | ||
* Undiagnosed type 2 diabetes | * Undiagnosed [[Diabetes mellitus type 2|type 2 diabetes]] | ||
* Prolonged hyperglycemia | * Prolonged [[hyperglycemia]] | ||
| | | | ||
* May have all clinical features of diabetes mellitus plus: | * May have all clinical features of [[diabetes mellitus]] plus: | ||
** | ** [[Hypotension]] | ||
** Dehydration | ** [[Dehydration]] | ||
** Tachycardia | ** [[Tachycardia]] | ||
** Decreased mentation | ** Decreased mentation | ||
** Focal neurological abnormalities | ** Focal [[neurological]] abnormalities | ||
| | | | ||
* Hyperglycemia (600-2000 mg/dl) | * [[Hyperglycemia]] (600-2000 mg/dl) | ||
* Increased serum osmolarity (330-380 mOsm/kg) | * Increased [[serum]] [[osmolarity]] (330-380 mOsm/kg) | ||
* Arterial pH >7.3 | * [[Arterial]] [[pH]] >7.3 | ||
* Anion gap normal | * [[Anion gap]] normal | ||
* No ketosis | * No [[ketosis]] | ||
|- | |- | ||
|Impaired glucose tolerance | |[[Impaired glucose tolerance]] | ||
| | | | ||
* Family history of diabetes | * [[Family history]] of [[Diabetes mellitus|diabetes]] | ||
* Obesity (BMI >25 kg/m2) | * [[Obesity]] ([[Body mass index|BMI]] >25 kg/m2) | ||
* Stress | * Stress | ||
* Sedentary lifestyle | * [[Sedentary lifestyle]] | ||
* History of gestational diabetes | * History of [[gestational diabetes]] | ||
* Acanthosis nigricans | * [[Acanthosis nigricans]] | ||
| | | | ||
* May have all clinical features of diabetes mellitus | * May have all clinical features of [[diabetes mellitus]] | ||
| | | | ||
* Hyperglycemia: | * [[Hyperglycemia]]: | ||
** Fasting blood glucose level: 100-125 mg/dl | ** [[Fasting blood sugar|Fasting blood glucose]] level: 100-125 mg/dl | ||
** Oral glucose tolerance test 140-200 mg/dl | ** [[Oral glucose tolerance test]]: 140-200 mg/dl | ||
|- | |- | ||
| rowspan="2" |Ketosis | | rowspan="2" |Ketosis | ||
|Alcoholic ketosis | |Alcoholic [[ketosis]] | ||
| | | | ||
* Non-diabetic chronic alcohol user | * Non-diabetic chronic [[alcohol]] user | ||
* Binge drinking history | * [[Binge drinking]] history | ||
* Fasting for 1-2 days after binge drinking | * Fasting for 1-2 days after [[binge drinking]] | ||
| | | | ||
* | * [[Nausea]] | ||
* Vomiting | * [[Vomiting]] | ||
* Diffuse abdominal pain | * Diffuse [[abdominal]] pain | ||
* Dehydration | * [[Dehydration]] | ||
* Stress | * Stress | ||
* Anorexia | * [[Anorexia]] | ||
| | | | ||
* Serum glucose normal (only 10% with serum glucose >250 mg/dl) | * [[Serum]] [[glucose]] normal (only 10% with [[serum]] [[glucose]] >250 mg/dl) | ||
* Serum bicarbonate < 18 mEq/L | * [[Serum]] [[bicarbonate]] < 18 mEq/L | ||
* Arterial pH may show acidosis or may be alkalotic due to respiratory alkalosis | * [[Arterial]] [[pH]] may show acidosis or may be [[Alkalosis|alkalotic]] due to [[respiratory alkalosis]] | ||
* Increased anion gap | * Increased [[anion gap]] | ||
* Acetoacetate and beta hydroxybutyrate elevated | * [[Acetoacetate]] and beta hydroxybutyrate elevated | ||
|- | |- | ||
|Starvation ketosis | |Starvation [[ketosis]] | ||
| | | | ||
* Several weeks of low caloric intake | * Several weeks of low [[Calories|caloric]] intake | ||
* Malnourishment | * [[Malnourishment]] | ||
| | | | ||
* Halitosis | * [[Halitosis]] | ||
* Dehydration | * [[Dehydration]] | ||
* Dry coated tongue | * Dry coated [[tongue]] | ||
* Confusion | * [[Confusion]] | ||
* Drowsiness | * [[Drowsiness]] | ||
* Cold extremities | * Cold [[extremities]] | ||
* Hypotension (postural or supine) | * [[Hypotension]] (postural or supine) | ||
* Leg cramps | * [[Leg cramps]] | ||
| | | | ||
* Serum glucose normal or hypoglycemia | * [[Serum]] [[glucose]] normal or [[hypoglycemia]] | ||
* Serum bicarbonate > 18 mEq/L | * [[Serum]] [[bicarbonate]] > 18 mEq/L | ||
* Arterial pH may show acidosis | * [[Arterial]] [[pH]] may show [[acidosis]] | ||
* Increased anion gap | * Increased [[anion gap]] | ||
|- | |- | ||
| rowspan="4" |Metabolic acidosis | | rowspan="4" |Metabolic acidosis | ||
|Lactic acidosis | |[[Lactic acidosis]] | ||
| | | | ||
* Hypermetabolic states: | * [[Hypermetabolic]] states: | ||
** Trauma | ** [[Trauma]] | ||
** Burns | ** [[Burns]] | ||
** Sepsis | ** [[Sepsis]] | ||
* Hypoxia | * [[Hypoxia]] | ||
* Short bowel syndrome | * [[Short bowel syndrome]] | ||
* Jejuno-ileal bypass surgery | * [[Jejuno-ileal bypass|Jejuno-ileal bypass surgery]] | ||
* Chronic pancreatic insufficiency | * [[Chronic pancreatitis|Chronic pancreatic insufficiency]] | ||
* Chronic renal insufficiency | * [[Chronic renal insufficiency]] | ||
* Large carbohydrate intake | * Large [[carbohydrate]] intake | ||
* Carbon monoxide poisoning | * [[Carbon monoxide poisoning]] | ||
* | * Drug intake: | ||
** Cyanide | ** [[Cyanide]] | ||
** Salicylates | ** [[Salicylates]] | ||
** Biaguanides | ** Biaguanides | ||
** INH | ** [[Isoniazid|INH]] | ||
** Anti-retroviral agents | ** [[AIDS antiretroviral drugs|Anti-retroviral agents]] | ||
** Valproic acid | ** [[Valproic acid]] | ||
* COPD | * [[Chronic obstructive pulmonary disease|COPD]] | ||
* Asthma | * [[Asthma]] | ||
* Mesenteric ischemia | * [[Mesenteric ischemia]] | ||
| | | | ||
* Neurological: | * [[Neurological]]: | ||
** Confusion | ** [[Confusion]] | ||
** Stupor | ** [[Stupor]] | ||
* Slurred speech | * [[Slurred speech]] | ||
* Nausea | * [[Nausea]] | ||
* Vomiting | * [[Vomiting]] | ||
* Warm extremities | * Warm [[extremities]] | ||
* Dyspnea | * [[Dyspnea]] | ||
* Cough | * [[Cough]] | ||
* Tachycardia | * [[Tachycardia]] | ||
* Weakness | * [[Weakness]] | ||
* Fatigue | * [[Fatigue]] | ||
| | | | ||
* Arterial pH <7.3 | * [[Arterial]] [[pH]] <7.3 | ||
* Increased anion gap | * Increased [[anion gap]] | ||
* Increased blood lactate | * Increased [[blood]] [[lactate]] | ||
|- | |- | ||
|Salicylic acid ingestion | |Salicylic acid ingestion | ||
Revision as of 19:22, 22 August 2017
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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]
- Other conditions causing hyperglycemia
- Other conditions causing ketosis
- Ketotic hypoglycemia
- Alcoholic ketosis
- Starvation ketosis
- Other conditions causing metabolic acidosis
- Lactic acidosis
- Salicylic acid ingestion
- Uremic acidosis
- Drug-induced acidosis
| Characteristic Common to DKA | Condition | History Findings | Clinical Features | Lab abnormalities |
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| Hyperglycemia | Diabetes mellitus |
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| Non-ketotic hyperosmolar state |
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| Impaired glucose tolerance |
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| Ketosis | Alcoholic ketosis |
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| Starvation ketosis |
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| Metabolic acidosis | Lactic acidosis |
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| Salicylic acid ingestion |
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| Uremic acidosis |
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| Drug-induced acidosis |
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Differential diagnosis of increased anion gap metabolic acidosis
- Causes of increased anion gap metabolic acidosis can be differetiated from each other with the help of following alogrhythm:[9][10][11][12][13]
| ↑ 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
- ↑ "Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician".
- ↑ 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.
- ↑ 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.
- ↑ Joseph F, Anderson L, Goenka N, Vora J (2009). "Starvation-induced true diabetic euglycemic ketoacidosis in severe depression". J Gen Intern Med. 24 (1): 129–31. doi:10.1007/s11606-008-0829-0. PMC 2607495. PMID 18975036.
- ↑ Williams HE (1984). "Alcoholic hypoglycemia and ketoacidosis". Med. Clin. North Am. 68 (1): 33–8. PMID 6361416.
- ↑ Durnas C, Cusack BJ (1992). "Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it". Drugs Aging. 2 (1): 20–34. PMID 1554971.
- ↑ Gokel Y, Paydas S, Koseoglu Z, Alparslan N, Seydaoglu G (2000). "Comparison of blood gas and acid-base measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room". Am. J. Nephrol. 20 (4): 319–23. doi:13607 Check
|doi=value (help). PMID 10970986. - ↑ 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.
- ↑ Lim S (2007). "Metabolic acidosis". Acta Med Indones. 39 (3): 145–50. PMID 17936961.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Warnock DG (1988). "Uremic acidosis". Kidney Int. 34 (2): 278–87. PMID 3054224.