What are the diagnostic criteria for Diabetic Ketoacidosis (DKA)?

From the Guidelines

Diabetic ketoacidosis (DKA) is diagnosed based on three key criteria: hyperglycemia (blood glucose >250 mg/dL), metabolic acidosis (venous pH <7.3 and serum bicarbonate <18 mEq/L), and ketosis (elevated serum and urine ketones) 1. The diagnosis of DKA should be made based on the presence of these three criteria, with a focus on the measurement of beta-hydroxybutyrate in blood for diagnosis and monitoring of DKA 1. Some key points to consider in the diagnosis of DKA include:

• Hyperglycemia: blood glucose >250 mg/dL
• Metabolic acidosis: venous pH <7.3 and serum bicarbonate <18 mEq/L
• Ketosis: elevated serum and urine ketones
• Measurement of beta-hydroxybutyrate in blood is preferred for diagnosis and monitoring of DKA 1 Initial evaluation should include a comprehensive metabolic panel, complete blood count, urinalysis for ketones, serum ketones (beta-hydroxybutyrate), venous blood gas, and an electrocardiogram. Additional tests to consider are HbA1c, serum osmolality, and appropriate cultures if infection is suspected. The diagnostic workup should also identify potential precipitating factors such as infection, medication non-compliance, myocardial infarction, stroke, trauma, or surgery. It's essential to note that euglycemic DKA can occur with blood glucose levels below 250 mg/dL, particularly in patients taking SGLT2 inhibitors or with reduced food intake. Differential diagnoses to consider include hyperosmolar hyperglycemic state, alcoholic ketoacidosis, starvation ketosis, and lactic acidosis. Early diagnosis is crucial as DKA is a medical emergency with significant mortality if not promptly treated with insulin, fluids, and electrolyte management.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Early signs of diabetic ketoacidosis include glycosuria and ketonuria Polydipsia, polyuria, loss of appetite, fatigue, dry skin, abdominal pain, nausea and vomiting and compensatory tachypnea come on gradually, usually over a period of some hours or days, in conjunction with hyperglycemia and ketonemia.

The diagnosis of Diabetic Ketoacidosis (DKA) is based on the presence of:

• Hyperglycemia (high blood glucose levels)
• Ketonuria (presence of ketones in the urine)
• Glycosuria (presence of glucose in the urine)
• Clinical symptoms such as:
  • Drowsy feeling
  • Flushed face
  • Thirst
  • Loss of appetite
  • Fruity odor on the breath
  • Heavy breathing
  • Rapid pulse
  • Polydipsia (excessive thirst)
  • Polyuria (excessive urination)
  • Fatigue
  • Dry skin
  • Abdominal pain
  • Nausea and vomiting 2 2

From the Research

Diagnosis of Diabetic Ketoacidosis (DKA)

• Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level, and dehydration 3.
• A diagnosis of DKA requires the patient's plasma glucose concentration to be above 250 mg per dL, the pH level to be less than 7.30, and the bicarbonate level to be 18 mEq per L or less 4.
• The diagnosis of DKA is confirmed when all three criteria are present: 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis 5.

Clinical Features and Laboratory Tests

• Common symptoms of DKA include polyuria with polydipsia, weight loss, fatigue, dyspnea, vomiting, preceding febrile illness, abdominal pain, and polyphagia 3.
• Measurement of A1C, blood urea nitrogen, creatinine, serum glucose, electrolytes, pH, and serum ketones; complete blood count; urinalysis; electrocardiography; and calculation of anion gap and osmolar gap can differentiate DKA from other metabolic syndromes 3.
• Beta-hydroxybutyrate is a better measurement of the degree of ketosis than serum ketones 4.

Importance of Early Diagnosis and Treatment

• Early diagnosis and management of DKA are paramount to improve patient outcomes 5.
• The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 5.
• Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality 5.