What is the expected ketone level in Diabetic Ketoacidosis (DKA)?

From the Guidelines

In diabetic ketoacidosis (DKA), ketone levels are typically elevated above 3.0 mmol/L when measured in blood or strongly positive (≥3+) when tested in urine, with beta-hydroxybutyrate levels often ranging from 4-10 mmol/L in severe cases, as indicated by the most recent and highest quality study 1.

Key Points

• Blood ketone measurements are more accurate than urine ketone testing, which can show moderate to large ketones (2+ to 4+) using dipstick methods.
• The accumulation of acidic ketone bodies leads to metabolic acidosis, typically with a pH below 7.3 and bicarbonate below 18 mEq/L.
• Insulin deficiency combined with increased counter-regulatory hormones (glucagon, cortisol, catecholamines) causes the liver to convert fatty acids into ketone bodies (acetoacetate, beta-hydroxybutyrate, and acetone).
• Measuring both ketones and blood glucose (usually >250 mg/dL) is crucial in confirming the diagnosis and guiding treatment decisions, as stated in 1 and supported by 1 and 1.

Monitoring and Treatment

• Direct measurement of beta-hydroxybutyrate in the blood is the preferred method for monitoring DKA, as the nitroprusside method only measures acetoacetic acid and acetone, and may not accurately reflect the severity of ketosis, as noted in 1.
• Regular insulin by continuous intravenous infusion is the treatment of choice, unless the episode of DKA is mild, in which case regular insulin can be given subcutaneously or intramuscularly every hour, as recommended in 1 and 1.
• Fluid replacement and electrolyte management are critical in treating DKA, with the goal of correcting estimated deficits within the first 24 hours and avoiding iatrogenic fluid overload, as emphasized in 1 and 1.

From the Research

Expected Ketone Level in DKA

• The expected ketone level in Diabetic Ketoacidosis (DKA) can vary widely, with blood ketone levels ranging from 1.02-15.9 mmol/L in patients with DKA 2.
• A study found that blood ketone levels in patients with diabetic ketosis and those with DKA varied widely, 1.05-5.13 mmol/L and 1.02-15.9 mmol/L, respectively 2.
• The American Diabetes Association, the Joint British Diabetes Societies, and the American Association of Clinical Endocrinologists and the American College of Endocrinology have issued diagnostic criteria for DKA, which include the presence of high urinary or blood ketoacids 3.
• A diagnosis of DKA is confirmed when all of the 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 3.
• The management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event, as well as frequent monitoring of the patient's clinical and laboratory states 4.
• Blood ketone data need to be interpreted cautiously along with other biochemical data, and a new system is required to better characterize DKA 2.