What are the complications of diabetic ketoacidosis (DKA)?

Complications of Diabetic Ketoacidosis (DKA)

Diabetic ketoacidosis (DKA) is a serious, acute, and life-threatening hyperglycemic emergency that incurs substantial morbidity, mortality, and costs. 1 The complications of DKA can be categorized into acute complications during the crisis itself and complications that arise during treatment.

Acute Complications of DKA

Metabolic Derangements

• Severe hyperglycemia (typically >250 mg/dL), though approximately 10% of people with DKA present with euglycemic DKA (plasma glucose <200 mg/dL) 1
• Metabolic acidosis with increased anion gap due to ketone body accumulation 2
• Electrolyte imbalances, particularly hyperkalemia despite total-body potassium depletion 3
• Dehydration and volume depletion due to osmotic diuresis 1

Systemic Complications

• Altered mental status ranging from mild confusion to coma 2
• Respiratory distress with Kussmaul respirations (deep, rapid breathing) as compensation for metabolic acidosis 2
• Hypoxemia and, rarely, noncardiogenic pulmonary edema 1
• Gastrointestinal symptoms including nausea, vomiting, and abdominal pain that can mimic acute abdomen 4
• Increased risk of thromboembolism due to dehydration and hypercoagulable state 5

Treatment-Related Complications

Cerebral Edema

• Rare but potentially fatal complication occurring in 0.7-1.0% of children with DKA 1
• Most common in children with newly diagnosed diabetes but has been reported in young adults in their twenties 1
• Characterized by deterioration in level of consciousness, lethargy, and decreased arousal 1
• Risk factors include rapid correction of hyperglycemia and rapid changes in serum osmolality 1

Electrolyte Disturbances

• Hypokalemia can develop during treatment due to insulin administration and correction of acidosis 3
• Hypophosphatemia may occur during insulin therapy as phosphate shifts intracellularly 1
• Hypomagnesemia can develop and contribute to cardiac arrhythmias 6

Other Treatment Complications

• Hypoglycemia due to overzealous treatment with insulin 1
• Hyperchloremic metabolic acidosis caused by excessive saline administration during fluid resuscitation 1
• Fluid overload in patients with compromised cardiac or renal function 7

Long-Term Complications and Outcomes

Mortality Risk

• Overall mortality for children with DKA is <1% in the United States, though recent reports from tertiary care centers suggest lower rates 1
• Mortality is higher in patients with severe DKA (pH ≤7.1 and bicarbonate ≤5) 1
• Mortality among patients with hyperglycemic hyperosmolar state (HHS) is approximately 10-fold higher than that associated with DKA 6

Recurrent DKA

• Associated with higher incidence of psychiatric illness, especially depression 1
• More common in patients from single-parent homes and those who are underinsured 1
• Higher frequency of eating disorders in adolescents with recurrent episodes of DKA 1
• Significantly greater diabetes morbidity and mortality compared to patients without episodes of DKA 1

Special Populations

Pregnancy

• Up to 2% of pregnancies with pregestational diabetes (most often type 1 diabetes) are complicated by DKA 1
• Pregnant individuals may present with euglycemic DKA, making diagnosis more challenging 1
• Increased risk of fetal and maternal harm 1

Patients on SGLT2 Inhibitors

• Increased risk of euglycemic DKA in patients treated with SGLT2 inhibitors 1
• Risk factors include very-low-carbohydrate diets, prolonged fasting, dehydration, and excessive alcohol intake 1

Prevention Strategies

• Public awareness of the signs and symptoms of untreated diabetes 1
• Education of caregivers about the signs and symptoms of early DKA 1
• Recognition that insulin omission due to psychological problems and lack of financial resources is the most common cause of DKA in patients with established diabetes 1
• Improved detection of families at risk 1
• Education about ketone monitoring 1
• 24-hour telephone availability and encouragement to contact healthcare team when blood glucose levels are high or ketones are present 1

DKA remains a significant cause of morbidity and mortality in patients with diabetes. Early recognition, prompt treatment, and prevention strategies are essential to reduce the risk of complications and improve outcomes.