Characterization of variable presentations of diabetic ketoacidosis based on blood ketone levels and major society diagnostic criteria: a new view point on the assessment of diabetic ketoacidosis

Abstract

Aim

We aimed to evaluate the clinical utility of blood ketone measurement and to test the performance of the diagnostic criteria for diabetic ketoacidosis (DKA) issued by the American Diabetes Association, the Joint British Diabetes Societies, and the American Association of Clinical Endocrinologists and the American College of Endocrinology.

Methods

This retrospective analysis included 278 patients with suspected DKA who were hospitalized at 4 university hospitals and aged ≥16 years with a blood glucose level of >200 mg/dL and a blood ketone level of ≥1.0 mmol/L as well as other biochemical data. The patients were categorized into four subgroups (ketosis, typical DKA, atypical DKA, and DKA + lactic acidosis). Atypical DKA in each analysis was defined by our supplementary criteria if the biochemical data did not meet each set of diagnostic criteria from the aforementioned societies.

Results

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. Additionally, there were significant discrepancies between the guidelines in the diagnosis of DKA. Thus, the proportion of patients with atypical DKA ranged from 16.5% to 42.4%. Notably, the in-hospital mortality was comparable between patients with typical and atypical DKA, with a very high mortality in patients with DKA + lactic acidosis (blood lactate >5 mmol/L).

Conclusions

Our results showed that considering variable presentations of DKA, blood ketone data need to be interpreted cautiously along with other biochemical data and suggested that a new system is required to better characterize DKA.

Keywords:

• Diabetic ketoacidosis
• ketone bodies
• diagnosis
• lactic acidosis
• acid base imbalance

Acknowledgments

This study was supported by grants from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Korea (HI14C1135 and HI16C1997).

Summary

• The clinical parameters and criteria issued by major societies for the diagnosis of DKA are not concordant and blood ketone measurement is not standardized yet despite various analytic methods and options became available.

• We found that there were significant discrepancies between 3 major society guidelines in detecting DKA if applied strictly and that a single cutoff level of blood ketone could not be applied for the diagnosis of DKA because of wide variation of blood ketone levels and variable presentation of DKA.

• A new system is required to better characterize and diagnose DKA.

Supplementary materials

Table S1 Clinical and biochemical data at admission and in-hospital mortality rates of DKA patients (n=254) by the JBDS criteria and our supplementary criteria according to initial presentation patterns

Table S2 Clinical and biochemical data at admission and in-hospital mortality rates of DKA patients (n=254) by the AACE/ACE criteria and our supplementary criteria according to initial presentation patterns

Disclosure

No potential conflicts of interest relevant to this article were reported by the authors.