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Clinical Review

Diabetic ketoacidosis in adults

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5660 (Published 28 October 2015) Cite this as: BMJ 2015;351:h5660

This article has a correction. Please see:

  1. Shivani Misra, clinical research fellow and specialist trainee year 6 in metabolic medicine12,
  2. Nick S Oliver, consulant diabetologist and reader in diabetes13
  1. 1Department of Diabetes, Endocrinology & Metabolism, Imperial College, London W2 1PG, UK
  2. 2Clinical Biochemistry & Metabolic Medicine, Imperial Healthcare NHS Trust, London, UK
  3. 3Diabetes and Endocrinology, Imperial Healthcare NHS Trust, London, UK
  1. Correspondence to: N S Oliver nick.oliver{at}imperial.ac.uk

What you should know

  • Diabetic ketoacidosis (DKA) is a common, serious, and preventable complication of type 1 diabetes, with a mortality of 3-5%. It can also occur in patients with other types of diabetes

  • It can be the first presentation of diabetes. This accounts for about 6% of cases

  • The diagnosis is not always apparent and should be considered in anyone with diabetes who is unwell

  • Diagnosis is based on biochemical criteria. However, hyperglycaemia may not always be present and low blood ketone levels (<3 mmol/L) do not always exclude DKA

  • Immediate treatment consists of intravenous fluids, insulin, and potassium, with careful monitoring of blood glucose and potassium levels to avoid hypoglycaemia and hypokalaemia

  • Knowledge of the type of diabetes at the time of DKA does not affect immediate treatment, and all patients with DKA should be advised to continue with insulin on discharge

  • Subsequent management should focus on patient education and support to avoid recurrence

  • Patients should be managed by a specialist multidisciplinary team during and after an episode of DKA

What is DKA?

Diabetic ketoacidosis (DKA) is an extreme metabolic state caused by insulin deficiency. The breakdown of fatty acids (lipolysis) produces ketone bodies (ketogenesis), which are acidic. Acidosis occurs when ketone levels exceed the body’s buffering capacity (figure⇓).1 2

Diabetic ketoacidosis may follow absolute insulin deficiency or relative insulin deficiency. Relative insulin deficiency may occur in the presence of increased levels of counter-regulatory hormones such as glucagon, cortisol, and catecholamines. Insulin deficiency results in lipolysis and ketogenesis. Ketone bodies are acidic and may initially be buffered, but when levels are high enough, will result in acidosis

How common is DKA?

Data from the UK National Diabetes audit shows a crude one year incidence of 3.6% among people with type 1 diabetes.3 In the UK nearly 4% of people with type 1 diabetes experience DKA …

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