Cause Of Diabetic Ketoacidosis Research Articles

Prevalence and Associated Factors of Diabetic ketoacidosis among Patients Living with Type 1 Diabetes in Makkah Al-Mukarramah City

Objective: To assess magnitude of diabetic ketoacidosis (DKA) among type-1 diabetics and to identify associated risk factors. Methods: A cross-sectional study was conducted among 236 type-1 diabetics in Makkah Al-Mukarramah City, Saudi Arabia. Results: Among participants, 59.3% were males, 44.1% were diabetic for more than 5 years, while 70.8% reported past history of DKA. The main causes of DKA were gfirst presentation of the diseaseh (40.9%), and gdiscontinued treatmenth (37%). The HbA1c among 53.6% was above 9%. Almost all cases who experienced DKA were hospitalised (98.8%). Out of them, 9 (5.4%) suffered complications. Female patients were more likely to suffer from episodes of DKA than males (76% and 68.3%, respectively). Most patients whose parentsf highest education was primary level had DKA more frequently than those whose parentsf had postgraduate education. Patients with unemployed fathers had significantly higher frequency of DKA (p=0.004). Ketoacidosis was significantly more frequent among patients with parentsf consanguinity (p<0.001). Patients who had their current HbA1c level exceeding 9% had positive history of DKA compared to those with HbA1c level .7% (87.9% and 28.6%, respectively, p<0.001). Conclusion: Most type-1 diabetics experience DKA, mainly with their first presentation of disease or due to discontinuation of treatment. DKA tends to occur more frequently among female patients, those with less educated parents or when their parents are relatives. Key words: Type 1 diabetes, diabetic ketoacidosis, magnitude, risk factors.

Ketogenesis and Ketone Excretion Before and After Empagliflozin Use in Type 1 Diabetes

Adjunctive-to-insulin sodium glucose co-transporter 2 (SGLT2) inhibition has clinically meaningful benefits in type 1 diabetes (T1D) but represents a component cause of diabetic ketoacidosis (DKA) whose risk appears higher in females.

Случаи кетоацидоза на фоне приема сахароснижающих препаратов из группы ингибиторов натрий-глюкозного котранспортера у пациентов с сахарным диабетом

The diabetic ketoacidosis (DKA) is the most frequent urgent condition in patients with diabetes mellitus which requires hospitalization and results to mortality. The most common causes of DKA are the presence of concomitant diseases in diabetic patients, as well as the violation of the insulin therapy regimen. With the appearance of hypoglycemic drugs from the group of sodium-glucose co-transporter inhibitors (iSGLT2), isolated cases of DKA associated with their intake began to be recorded. This article describes 4 cases of ketoacidosis in patients with type 2 diabetes mellitus and type 1 diabetes mellitus taking dapagliflozin which is a hypoglycemic drug from the group of inhibitors of the sodium-glucose co-transporter.

DKA in Diet-Controlled Patient With Type 2 Diabetes and ESRD Precipitated by Acute COVID-19

Type 2 diabetes mellitus (T2DM) is the main factor for the global rise in end stage renal disease (ESRD), accounting for about 45% of the dialysis patient population in United States. Although T2DM is a common cause for ESRD, it is uncommon for well controlled T2DM patients on dialysis to develop DKA. The COVID-19 pandemic has highlighted infections as a precipitating cause of diabetic ketoacidosis (DKA) and stresses the importance of optimal glycemic control. We report a case of a previously diet controlled patient with T2DM and ESRD admitted with DKA and acute COVID-19. 46-year-old male with diet controlled T2DM, HIV (human immunodeficiency virus) on HAART (highly active antiretroviral therapy), ESRD secondary to HIV associated nephropathy was admitted from an outpatient dialysis unit with vomiting, chills and body aches. He was on metformin monotherapy prior to dialysis initiation. Regular self-monitored blood glucoses ranged 80-130mg/dl with HbA1C of 6% one month prior. Lab tests on admit revealed serum glucose 499mg/dl, elevated anion gap 21mmol/L, potassium 3.5mmol/L (3.5–5.0), HbA1C: 14.7%, elevated beta-hydroxybutyrate 5.6mmol/L(normal:<=0.4), CD4 count 500 (489–1457/µL) with an undetectable HIV viral load however COVID-19 polymerase chain reaction was detectable. He was managed with cautious fluid resuscitation requiring a total of one-liter normal saline, higher potassium dialysate (3K+), and continuous insulin infusion with resolution of abdominal symptoms and DKA. No other infections or precipitating factors were found and acute COVID-19 infection was managed symptomatically. He was discharged on basal bolus insulin regimen on day seven of admit. Up to a third of patients with diabetes on dialysis do not require anti-hyperglycemic therapy, such as our case. Potential factors leading to reduced insulin requirements include reduced renal insulin clearance,reduced renal gluconeogenesis, protein-energy wasting, reduced body weight and accumulation of uremic toxins (guanidino compounds postulated to act as biguanide agents). Our case highlights that acute COVID-19 can precipitate DKA in previously well controlled T2DM patients on hemodialysis while being aware of the need for cautious fluid and potassium administration due to lack of osmotic diuresis in anuric dialysis patients. Close self-monitoring of blood glucose should be emphasized in patients withT2DM with ESRD, including diet controlled T2DM patients, in order to reduce hyperglycemic emergencies and inpatient admissions especially during COVID-19 pandemic.

Incidence, characteristics and long-term outcomes of patients with diabetic ketoacidosis: a prospective prognosis cohort study in an emergency department.

Diabetic ketoacidosis is the most frequent hyperglycemic complication in the evolution of diabetes mellitus. Common precipitating factors include newly diagnosed diabetes mellitus, noncompliance with therapy and infections. However, few studies have been conducted in Brazil and none were prospective in design. To describe the incidence, clinical and laboratory characteristics and precipitating factors of diabetic ketoacidosis among emergency department patients in a tertiary-level teaching hospital in Brazil. We also aimed to identify immediate and long-term mortality within two years. Prospective prognosis cohort study conduct at a tertiary-level teaching hospital in São Paulo, Brazil. All patients > 12 years old presenting diabetic ketoacidosis who were admitted to the emergency department from June 2015 to May 2016 were invited to participate. The incidence of diabetic ketoacidosis per 1,000 admissions was 8.7. Treatment noncompliance and infection were the most common causes of diabetic ketoacidosis. The immediate mortality rate was 5.8%, while the six-month, one-year and two-year mortality rates were 9.6%, 13.5% and 19.2%, respectively. Death occurring within two years was associated with age, type 2 diabetes, hypoalbuminemia, infection at presentation and higher sequential organ failure assessment (SOFA) score at admission. Diabetic ketoacidosis among patients presenting to the emergency department was relatively frequent in our hospital. Treatment noncompliance and infection were major precipitating factors and presence of diabetic ketoacidosis was associated with immediate and long-term risk of death.

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is an acute metabolic disorder that occurs in those with Type 1 diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM) which presents with persistent hyperglycemia (≥250 mg/ dL) leading to a high anion gap metabolic acidosis with ketosis in the setting of either a relative or absolute insulin deficiency. Evaluation for the precipitating cause of DKA, such as trauma, infection, pump malfunction or medication noncompliance is essential. While DKA can be life-threatening, and hospitalizations for DKA are on the rise, adverse outcomes are minimal if promptly treated with aggressive fluid resuscitation, adequate insulin therapy and close monitoring of electrolytes. Prevention of future episodes of DKA is reliant upon adequate patient and caregiver education with a focus on treatment strategies in acute illness or with travel. The aim of this article is to provide a comprehensive overview of the epidemiology, clinical presentation, pathophysiology, treatment and prevention of DKA.

Causes of diabetic ketoacidosis among adults with type 1 diabetes mellitus: insulin pump users and non-users

IntroductionInsulin pumps are increasingly being used as a method of insulin delivery in patients with type 1 diabetes mellitus (T1DM). Diabetic ketoacidosis (DKA) is a serious complication of T1DM. This...

A Remarkable Elevation in the Procalcitonin Levels Due to Diabetic Ketoacidosis in a Hemodialysis Patient.

Procalcitonin (PCT), a marker of the inflammatory response during infections, can be elevated by diabetic ketoacidosis (DKA). A male patient in his 50s with diabetic nephropathy on hemodialysis presented with vomiting and a reduced level of consciousness and was diagnosed with DKA. His PCT level was markedly elevated, but bacterial cultures (blood, urine, and stool) were negative. The PCT level decreased after DKA improvement. In this patient, DKA probably enhanced the PCT levels. As DKA can increase the PCT levels, an elevation of the PCT levels in DKA patients may not be indicative of infectious diseases, and non-infectious causes of DKA should therefore be considered.

A Case Report : Diabetic Ketoacidosis in patient with type 1 Diabetes Mellitus with Complication Septic Shock and AKI Stage III on HD Triggered by Perianal Abscess

ABSTRACT&#x0D; Introduction. Diabetic ketoacidosis (DKA) is an acute, life-threatening complication in diabetes mellitus. Infection is a common precipitating cause of diabetic ketoacidosis (DKA) in known diabetic patient, and diabetic ketoacidosis (DKA) often presents as the first symptom of an undiagnosed diabetes. diabetic ketoacidosis (DKA) is diagnosed with combination of hyperglicaemia, acidosis metabolic and ketonuria.&#x0D; Case Presentation. A 27 years old male patient, admitted to Intensive Care Unit with decrease level of consciousness (GCS 3), he was intubated and present with respiratory distress, metabolic acidosis, high glucose level, ketonuria with renal failure as a target organ. Patient known has perianal abscess as a triggered of diabetic ketoacidosis (DKA), turn into septic shock and underwent debridement surgery to source control the infection. The patient was treated in intensive care unit for 9 days, and sent to ward with GCS 15 an no sequelae of organ failure. The treatment of diabetic ketoacidosis (DKA) should include correcting the often substantial hypovolemia, the hyperglycemia, electrolyte imbalance and the triggering factor of diabetic ketoacidosis (DKA).&#x0D; Conclusion. Prompt surgical intervention, antibacterial therapy, rapid restoration of glycemic control are crucial to prevent mortality in diabetes mellitus patients complicated with abscess.

SAT-672 An Unusual and Enigmatic Etiology for Diabetic Ketoacidosis: Safety Needles

Diabetic ketoacidosis is associated with a mortality rate of upto 6.1% and accounts for an estimated 115000 hospital discharges per year in the United States. In order to reduce mortality related to DKA, precipitating causes must be identified and addressed. The most common precipitant for DKA is infection with other precipitating factors including acute illness, medications and inadequate insulin therapy (1).A 76 year-old woman with type 2 diabetes was transferred from her assisted living facility for hyperglycemia. This was her fifth admission in the last month and a half attributed to either hyperglycemia or DKA. Her medications included insulin glargine and insulin aspart. She mentioned compliance with her insulin as well as her diabetic diet. In the ER, her vitals were stable with physical examination showing an obese woman in no acute distress. Her labs showed a blood glucose of 780, an anion gap of 17 and positive serum ketones. Further investigation did not reveal a source of infection or ischemia. The patient was treated in the ICU with intravenous insulin and fluids with resolution of her ketoacidosis. The patient was discharged with a 67% increase in her prandial insulin. On further review, her facility had recently required safety needles to be used for insulin pens. Patient was asked to demonstrate her technique with observation that patient was not pushing down enough to allow for the needle to enter her skin with subsequent trapping of her insulin within the needle. Prior to discharge, she was educated on proper administration of her insulin and since her discharge, she has had no subsequent readmissions for hyperglycemia.Hospitals and long-term facilities are the primary utilizers of needles with a retractable safety shield. Reduction of accidental puncture, elimination of reuse of needles and helping patients overcome anxiety about needles are some of the key advantages of these needles. Upon application of pressure onto the skin, the automatic shield or plastic cannula retracts and thus hides the needle before, during and after the injection. The major disadvantage is insulin being deployed while the needle is outside the body if incorrectly applied. Therefore, appropriate administration must be taught to the patient, including perpendicular insertion of the needle into the subcutaneous tissue and ensuring a more firm surface by injecting into a lifted skin fold. Legislation in the US has been passed requiring safety-engineered devices when feasible.In situations where the safety-engineered devices can impair effectiveness or cause harm, alternative approaches can be utilized, including insulin syringes or self-administration of insulin along with safe work procedures (1).1. Yu Catherine H.Y.. “Safety” technology: a hidden cause of diabetic ketoacidosis. Canadian Medical Journal Journal. 2012 Mar 20;184(5):557–558.

MON-LB125 Dka From a Ketogenic Diet and Intermittent Fasting or Ketosis-Prone Diabetes?

Background: Ketogenic diets and intermittent fasting (IF) are popularly used for weight loss. Generation of ketone bodies for fuel from fatty acid oxidation underlies both diets, combined or separately. We present a case of a prediabetic patient admitted for DKA after starting a combination keto/IF diet. Clinical Case: A 63-year-old man with hypertension, prediabetes, and alcohol use was admitted from clinic after receiving lab test results consistent with diabetic ketoacidosis (DKA). Two months ago, he had started a keto diet with IF (5 days/week, 18 hour fast/day) and achieved weight loss of 20 pounds. He reported polyuria and polydipsia, which was attributed to the recent initiation of chlorthalidone. Laboratory testing revealed glucose 519 (</= 199 mg/dL), bicarbonate 12 (20-30 mmol/L), creatinine 1.6 (0.5-1.5 mg/dL), anion gap of 23 (6-16 mEq/L), HbA1c 12.2% (4-5.6%), c-peptide 1.37 (0.80-3.85 ng/mL) with glucose 294, GAD65 Ab <5 (<5 IU/mL), IA2 Ab <5.4 (<5.4 U/mL), Insulin Ab <0.4 (<0.4 U/mL), triglyceride 546 (0-199 mg/dL), LDL-d 176 (0-129 mg/dL), cholesterol 310 (0-199 mg/dL) and HDL 39 (>/= 40 mg/dL). Workup for precipitating causes of DKA was negative including normal lactate, lipase and troponin. The patient was managed with an insulin drip and discharged on subcutaneous insulin (Lantus 45 units/day, Aspart 13 units with meals) and metformin. The patient re-introduced carbohydrates into his diet after meeting with the nutritionist. Eight weeks later, the HbA1c decreased to 6.6% and insulin was significantly reduced to Lantus 25 units/day. Sixteen weeks after discharge, the HbA1c further declined to 5.1% and Lantus was reduced to 10 units/day. Beta cell function at that time was preserved as evidenced by c-peptide 1.82 ng/mL. Insulin therapy was discontinued and the patient was closely monitored for urinary ketones and recurrence of hyperglycemia, neither which have developed. Conclusion: This is a unique case of DKA precipitated by a keto/intermittent fasting diet, without the use of SGLT2 inhibitor. Interestingly, previous metabolic studies show that nutritional ketosis typically generates low levels of serum ketones without a clinically significant anion gap metabolic acidosis. With negative beta cell autoantibodies and preserved beta cell function, this presentation is also consistent with ketosis-prone diabetes type 2B. It is possible that nutritional ketosis triggered the onset of KPD, although the mechanism remains unclear particularly since it is known that lipotoxicity is not pathogenic in the development of KPD.

Antimicrobial stewardship in diabetic ketoacidosis: a single-centre experience.

Diabetic ketoacidosis (DKA) is a common and serious complication arising predominantly in patients with type 1 diabetes mellitus. International data demonstrate that infection is one of the most common precipitating causes of DKA. Currently there are limited data regarding the role of antimicrobial stewardship (AMS) in this setting. To provide epidemiologic data regarding infections precipitating DKA, microbiological aetiology and antimicrobial prescribing practices in order to inform AMS interventions. Retrospective chart review of all type 1 diabetes mellitus DKA presentations from May 2015 to June 2018. In total, 249 DKA presentations occurred in 111 patients. Suspected infection accounted for 100/249 (40%) presentations, and only 36/249 (14.5%) were proven or probable infections. Skin and soft tissue infection was the most common (9/36, 25%), followed by urinary tract infection (8/36, 22%) and respiratory tract infection (7/36, 19%). A pathogen was identified in 24/100 presumed infections and included Staphylococcus aureus (24, 46%), Klebsiella pneumoniae (4/24, 17%) and Escherichia coli (3/24, 13%). No viral pathogens were identified. Of 80 empirical antimicrobial prescriptions, 75% were inappropriate based on guideline management of the documented suspected infection. Single agent ceftriaxone was appropriately prescribed in 7/23 (30%) cases, and was most frequently prescribed overall 23/80 (29%). This study demonstrates a lower incidence of infection compared to most previous publications, and suggests that infection-precipitated DKA may be over reported. Furthermore, our findings provide support for the role of AMS in the management of DKA.

Predictors and treatment outcome of hyperglycemic emergencies: a one-center experience

Background Hyperglycemic emergencies (HEs) are serious acute complications of uncontrolled diabetes, which can be life threatening. In spite of major advances in diagnosis and treatment, it still is an important cause of morbidity and mortality. Aims To evaluate treatment outcomes among diabetic patients presented with HEs and to ascertain the determinants and factors associated with the outcome. Patients and methods This prospective, longitudinal study was conducted on 240 diabetic patients presented with HEs at Specialized Medical Hospital, Mansoura University. They were subjected to full history, physical examination, laboratory assessment, and follow-up. According to the laboratory results, patients were divided into three groups: diabetic ketoacidosis (DKA); hyperglycemic hyperosmolar nonketotic state (HHS); and normo-osmolar nonketotic hyperglycemic state. Results The study included 82 men and 158 women. The most common HE was DKA. Nonadherence to medications was the most common cause of DKA and normo-osmolar nonketotic hyperglycemic state (52.1 and 47.8%, respectively). The overall hospital mortality due to HEs was 12.5%. The highest mortality was recorded in the HHS group (51.7%). Mortality was higher in old-aged, nonobese patients, and in those without education. Nonsurvivors had longer duration of ICU stay than survivors, with no difference in total hospital stay. No hypoglycemic episodes detected in the nonsurvived group versus 37 episodes in the survived one. There were significant associations between mortality and Glasgow coma scale, the presenting and the highest random plasma glucose, serum sodium, osmolarity, creatinine, white blood cells, and glycated hemoglobin. Conclusion DKA is the most common HE, while HHS has the highest mortality rate. The strongest predictors of mortality of HEs are HHS, DKA in type 2 diabetes, old age, chronic kidney disease, coronary artery disease, highest random plasma glucose, glycated hemoglobin, and length of ICU stay.

Clinical and biochemical profile, precipitants and prognostic factors of diabetic ketoacidosis: A retrospective study from a tertiary care center of north India

BackgroundWe aimed to retrospectively investigate the clinical and biochemical profile of Diabetic ketoacidosis (DKA) patients and various precipitating and prognostic factors. MethodsThis was a hospital-based retrospective observational study, conducted in a tertiary care hospital in north India, from March 2014 to March 2017. ResultsAmong 50 patients who satisfied the study criteria, 10 (20%) had DKA as their first presentation. Most common symptoms were nausea and vomiting (74%). Noncompliance was the major precipitating cause in 26 cases (52%) followed by infections in 18 cases (36%). The mean value of blood sugar at presentation was 406.8 ± 130.4 mg/dl with serum ketone 5.38 ± 1.56 mmol/l and mean pH 7.128 ± 0.157 with severe DKA in 14 (28%) patients. Mean duration of hospital stay was 8.2.±5.0 days, and low hemoglobin (p = 0.019) and high pulse rate (p = 0.025) were independent predictors of a longer stay. ConclusionWith intensive care, mortality did not occur; however, non-compliance remained the most common precipitating cause of DKA followed by infections.

2317-PUB: Diabetic Ketoacidosis in Adult Type 1 Diabetes Mellitus Patients on Insulin Pumps

Background: Insulin pumps are increasingly being used as a method of insulin delivery in patients with type 1 diabetes mellitus (T1DM). Diabetic ketoacidosis (DKA) is a serious complication of T1DM. This study aims to identify causes of DKA in T1DM patients on insulin pump, and to compare these with patients with T1DM on multiple daily insulin injections (MDII). Methods: This was a prospective observational pilot study assessing DKA between 2 groups of patients with T1DM: (1) on insulin pump and (2) on MDII. Demographic and clinical data were obtained from chart review. Patients’ knowledge on insulin and diabetes care was assessed with a questionnaire we devised. Results: We enrolled 17 adult patients - 12 on insulin pump (7 Medtronic, 3 Tandem, 2 Animas) and 5 on MDII - who were admitted to the ICU for DKA management. Eleven (65%) were females, all were Caucasian, with median age in pump users 27.0 years (IQR 22.5,39.5) vs. MDII 38.0 (IQR 32.0,51.0)(p=0.045). The rest of the demographic data were comparable. Majority of the patients on insulin pump had a pump &amp;gt;5 years and had the current pump &amp;lt;5 years. Six were given pump training in the physician’s office and 6 by the insulin pump company. In patients on insulin pump, 41% of DKA cases were pump- and tubing- related, 41% were due to non-adherence and 18% were due to an infection. In contrast, all the MDII patients had DKA due to non-adherence. Insulin pump patients had significantly higher adherence (p= 0.014) and better knowledge of managing hyperglycemia on sick days (p = 0.029) than MDII patients. Conclusion: A significant proportion of DKA in pump users was due to pump issues. Non-adherence was common in both pump users and MDII. Continued education on pump use may reduce the rate of DKA in pump users. Disclosure M. Amir: None. S. Al Ashi: None. M. Lansang: None. M. Al-Jaghbeer: None.

SAT-470 A Case of Acromegaly with Concomitant Hypercortisolism Presenting with Diabetic Ketoacidosis

Background: Acromegaly is a rare disorder with an annual incidence of 4-6 new cases per 1 million population.1 Impairment in glucose metabolism has been previously described in such disorder, but diabetic ketoacidosis is rare. Case: A 25 year old, male, presented at our emergency room with seizures. Laboratory data showed hyperglycemia (blood glucose 418 mg/dl), ketonuria (urine ketone +2), and pure high anion gap metabolic acidosis consistent with severe Diabetic Ketoacidosis. Hba1c was 12%. A normal fasting C-peptide 1.68 ng/ml (1.10-4.40 ng/ml) indicate residual insulin secretion, or maybe an inappropriately normal response in the presence of severe hyperglycaemia hyperglycemia. Features of acromegaly were noted and hormonal evaluation showed elevated IGF-1 level at 484.50 ng/ml (83-344 ng/ml), supporting the diagnosis. Random growth hormone was elevated at 5.7 ng/ml (<3 ng/ml). GH suppression testing with oral glucose load was not done due to unstable glucose levels. An elevated 24 hour urine cortisol 6208.0 nmol (100.0-379.0 nmol/24h) may be associated with uncontrolled diabetes, or an underlying subclinical Cushing’s disease contributing to further insulin resistance. Other hormones of the anterior pituitary reveal normal thyroid function, central hypogonadism and hyperprolactinemia at 828.50 uIU/ml (58.0-475.0 uIU/ml) likely due to hypophyseal stalk compression by the tumor. Cranial MRI with contrast showed an enhancing sellar mass measuring 23.7 x 22.3 x 18.0 mm (AP x T x CC) which extends inferiorly to the upper portion of the prepontine cistern. Resolution of ketoacidosis required 360 units of regular insulin per day, without achieving target blood glucose levels. Blood glucose level was successfully controlled with insulin and oral hypoglycemic agents. There was incomplete resection of the mass following transphenoidal surgery. Conclusion: This case highlights the concomitant presence of increased counter regulatory hormones (GH and cortisol) and IGF-l levels in Acromegaly leading to increased insulin resistance, which are uncommon, but important causes of Diabetic Ketoacidosis. Reference: Melmed, S. (2016). Williams textbook of endocrinology. Elsevier Health Sciences.

Precipitating Factors for Diabetic Ketoacidosis among Patients with Type 1 Diabetes Mellitus: The Effect of Socioeconomic Status

Background: Diabetic ketoacidosis (DKA) is one of the life-threatening acute complications of diabetes mellitus that mainly occurs in type 1 diabetes mellitus (T1DM). This study aimed to determine the socioeconomic factors associated with DKA in patients with T1DM in Basrah. Methods: A cross-sectional study including patients with T1DM who were admitted due to DKA or any other complaint in any of the teaching hospitals in Basrah, from February to October 2017. Data collection from each patient or their parents using a questionnaire was designed to capture personal, social, and disease-related factors. Results: One hundred forty-seven patients were involved in this study. They were compared with different factors to assess correlations with the risk of DKA. Younger age, underweight, being without a job, low personal and/or mother educational level, travel, home glucose monitoring less than 7 times a week, uncontrolled HbA_1c and insulin stoppage as a cause of DKA regardless of the reasons to stop were associated with an increased risk of DKA. On the other hand, own home, availability of a glucometer for checking glucose, basal-bolus insulin regimen, insulin supply, and education at a tertiary center, correct injection technique whoever injected the insulin and dietary adherence, all were associated with a decreased risk of DKA. Other factors like gender, marital status, smoking status, father educational level, residency, income, personal home area, the frequency of HbA_1c checking, and family history of diabetes were not associated with a significant effect on the DKA risk. Conclusions: Multiple socioeconomic factors interact to play a vital role in the development of DKA among patients with T1DM in Basrah.

Substrate metabolism, hormone and cytokine levels and adipose tissue signalling in individuals with type 1 diabetes after insulin withdrawal and subsequent insulin therapy to model the initiating steps of ketoacidosis.

Lack of insulin and infection/inflammation are the two most common causes of diabetic ketoacidosis (DKA). We used insulin withdrawal followed by insulin administration as a clinical model to define effects on substrate metabolism and to test whether increased levels of counter-regulatory hormones and cytokines and altered adipose tissue signalling participate in the early phases of DKA. Nine individuals with type 1 diabetes, without complications, were randomly studied twice, in a crossover design, for 5h followed by 2.5h high-dose insulin clamp: (1) insulin-controlled euglycaemia (control) and (2) after 14h of insulin withdrawal in a university hospital setting. Insulin withdrawal increased levels of glucose (6.1 ± 0.5 vs 18.6 ± 0.5mmol/l), NEFA, 3-OHB (127 ± 18 vs 1837 ± 298μmol/l), glucagon, cortisol and growth hormone and decreased HCO3- and pH, without affecting catecholamine or cytokine levels. Whole-body energy expenditure, endogenous glucose production (1.55 ± 0.13 vs 2.70 ± 0.31mgkg-1min-1), glucose turnover, non-oxidative glucose disposal, lipid oxidation, palmitate flux (73 [range 39-104] vs 239 [151-474] μmol/min), protein oxidation and phenylalanine flux all increased, whereas glucose oxidation decreased. In adipose tissue, Ser473 phosphorylation of Akt and mRNA levels of G0S2 decreased, whereas CGI-58 (also known as ABHD5) mRNA increased. Protein levels of adipose triglyceride lipase (ATGL) and hormone-sensitive lipase phosphorylations were unaltered. Insulin therapy decreased plasma glucose concentrations dramatically after insulin withdrawal, without any detectable effect on net forearm glucose uptake. Release of counter-regulatory hormones and overall increased catabolism, including lipolysis, are prominent features of preacidotic ketosis induced by insulin withdrawal, and dampening of Akt insulin signalling and transcriptional modulation of ATGL activity are involved. The lack of any increase in net forearm glucose uptake during insulin therapy after insulin withdrawal indicates muscle insulin resistance. ClinicalTrials.gov NCT02077348 FUNDING: This study was supported by Aarhus University and the KETO Study Group/Danish Agency for Science Technology and Innovation.

Diabetic ketoacidosis as a reason for hospitalization in adult patients with any type of diabetes mellitus

Introduction. Diabetic ketoacidosis (DKA) is an acute complication of any type of diabetes, but most commonly is associated with type 1 diabetes mellitus (T1D). This condition is a complex metabolic disorder resulting from significant relative or absolute deficiency of insulin, which still leads to excess of mortality and health care burden. The main aim of the study was to assess the direct cause of DKA and to determine population at-risk among patients with greater predisposition to develop DKA, in order to propose methods and range of their education in the future. Materials and methods. This study presents a retrospective analysis of 120 cases of DKA (102 adults with diabetes) hospitalized in the Department of Internal Medicine and Diabetology at the Central Teaching Hospital of Medical University of Lodz between 2014 and 2017. Results. 68.4% of patients with DKA were T1D and LADA, 15.0% were T2D, 5.8% presented other types of diabetes and 10.8% were de novo diabetes. The mean age was 40.5 ± 17.7 years, diabetes duration 11.1 ± 9.74 years, HbA1c was 11.8 ± 2.54%. The main reason for hospitalization of patients for DKA was alcohol abuse (32.5%),followed by infection (23.4%), discontinuation of insulin treatment due to other reasons (13.4%), de novo diabetes (10.8%), lack of compliance (5.8%), mental disorders (5.8%) and complex causes (3.3%). In 5.0% of patients the reason could not be determined. All patients recovered, there was no death resulting of DKA. Conclusions. DKA occurs most frequently in T1D, but may be associated with type 2 or other types of diabetes. Most of our patients had a history of longterm poor control of diabetes. In many cases DKA, e.g. resulting from alcohol abuse or lack of compliance, probably can be avoided when proper patient education was given.

Risk and Relevance of Insulin Pump Therapy in the Aetiology of Ketoacidosis in People with Type 1 Diabetes.

The aim of this systematic data analysis was to determine the prevalence of diabetic ketoacidosis (DKA) as well as hypoglycemic and hyperglycemic disorders during insulin pump therapy (CSII) in patients with type 1 diabetes. The main focus was to investigate whether CSII patients have more DKA than the general type 1 diabetes population. This retrospective study with patients who were treated in our treatment center from 2003 to 2016 includes data from 229 patients (52.4% male, 47.6% female, 37.2±16.3 years; DKA: 93, hypoglycemia: 66, hyperglycemia: 70). Intensified insulin therapy was the most common treatment regimen in the study cohort (73.4%), followed by CSII (24%). However, 32.3% of the patients with DKA were on CSII. This number of DKA cases among the insulin pump users in our study cohort was higher than the prevalence reported in a previously published study by Reichel et al. (2013; p<0.05) and in a customer database (p<0.005). Most common causes of DKA in our study cohort were patient errors (43.3%) or insulin resistance induced by an underlying infection (29.8%). Device malfunction caused 13.5% of all DKA cases with an overwhelming majority on insulin pump treatment (93%). Overall, patient errors caused more DKA cases than device malfunctions. Our findings suggest that despite development of more sophisticated insulin pump devices, DKA is still more frequent with CSII than with other kinds of insulin treatment.