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Diabetic Ketoacidosis (DKA)

Diabetic Ketoacidosis (DKA) is an acute, life-threatening metabolic complication of diabetes caused by severe insulin deficiency, resulting in hyperglycemia, ketone production, and metabolic acidosis

Also called

Diabetic ketoacidotic crisis

ICD-10

E13.1

Specialty

Endocrine

Onset

Acute

Reviewed

August 2026

On This Page

Overview

–Diabetic Ketoacidosis (DKA) occurs when insulin deficiency is combined with increased counter-regulatory hormones such as glucagon, cortisol, catecholamines, and growth hormone.

-This causes:

  • Increased blood glucose
  • Increased lipolysis
  • Increased ketone production
  • Metabolic acidosis
  • Dehydration
  • Electrolyte disturbances
  • DKA is most commonly associated with Type 1 Diabetes Mellitus, but it can also occur in Type 2 Diabetes Mellitus

Etiology & Risk Factors

Etiology:

Diabetic Ketoacidosis (DKA) results from absolute or relative insulin deficiency combined with increased counter-regulatory hormones.

-Common precipitating factors include:

  • New-onset Type 1 Diabetes Mellitus
  • Missed or inadequate insulin doses
  • Infection
  • Acute myocardial infarction
  • Stroke
  • Pancreatitis
  • Surgery

-Risk Factors

  • Type 1 Diabetes Mellitus
  • Missed insulin doses
  • Inadequate insulin therapy
  • Infection
  • Acute illness
  • Myocardial infarction

Pathophysiology

Insulin deficiency + increased counter-regulatory hormones → decreased glucose utilization + increased hepatic glucose production → hyperglycemia → osmotic diuresis → dehydration and electrolyte loss

Insulin deficiency → increased lipolysis → free fatty acids → hepatic ketogenesis → β-hydroxybutyrate + acetoacetate → metabolic acidosis → compensatory Kussmaul respiration

Acidosis + dehydration + electrolyte abnormalities → impaired cellular function → altered mental status → severe DKA/coma if untreated

Clinical Presentation

-Symptoms

  • Polyuria
  • Polydipsia
  • Nausea
  • Vomiting
  • Abdominal pain
  • Weakness
  • Altered mental status
  • Shortness of breath or deep breathing

-Signs

  • Dehydration
  • Dry mucous membranes
  • Tachycardia
  • Hypotension
  • Tachypnea
  • Kussmaul respirations
  • Fruity/acetone breath
  • Altered consciousness in severe cases

-Severe Disease

Severe DKA may cause:

  • Severe dehydration
  • Hypotension
  • Shock
  • Severe metabolic acidosis
  • Marked electrolyte abnormalities
  • Coma

History Taking

-Ask about:

  • Known diabetes and type
  • Current insulin regimen
  • Missed or reduced insulin doses
  • Recent changes in insulin therapy
  • Blood glucose measurements
  • Blood or urine ketone measurements
  • Polyuria
  • Polydipsia
  • Altered consciousness
  • Recent infection
  • Fever

Physical Examination

-General Examination

  • Assess airway, breathing, and circulation
  • Level of consciousness
  • Degree of dehydration
  • Heart rate
  • Blood pressure
  • Respiratory rate

Look for:

  • Dry mucous membranes
  • Poor skin turgor
  • Tachycardia
  • Hypotension
  • Kussmaul respirations
  • Fruity breath
  • Reduced consciousness

System-Specific Examination

-Cardiovascular:

  • Tachycardia
  • Hypotension
  • Assess for myocardial infarction when clinically suspected

-Respiratory:

  • Tachypnea
  • Kussmaul respirations

-Abdominal:

  • Abdominal tenderness
  • Nausea and vomiting

-Neurological:

  • Mental status
  • Glasgow Coma Scale when appropriate

Investigations

-Complete Blood Count

  • May show:
  • Hemoconcentration due to dehydration
  • Leukocytosis, which may occur because of physiological stress or infection
  • A raised white blood cell count does not automatically indicate infection.

-Peripheral Blood Film

  • Usually has no specific diagnostic finding.
  • It may be performed when another hematological condition is suspected.

-Biochemistry / Specific Tests

  • Essential investigations include:
  • Capillary or plasma glucose
  • Serum or capillary β-hydroxybutyrate
  • Venous blood gas
  • Serum electrolytes
  • Sodium
  • Potassium
  • Bicarbonate
  • Urea
  • Creatinine
  • Calculated anion gap

–Additional investigations may include:

  • Urinalysis
  • Urine ketones
  • HbA1c
  •  

-Typical biochemical abnormalities

  • Elevated glucose
  • Elevated ketones
  • Low bicarbonate
  • Metabolic acidosis
  • Increased anion gap

Diagnosis

-DKA is established by demonstrating:

  • Diabetes or significant hyperglycemia
  • Elevated circulating ketones
  • Metabolic acidosis

 

-Typical findings include:

  • Elevated β-hydroxybutyrate
  • Low venous pH
  • Low serum bicarbonate
  • Increased anion gap
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Management

1. First-Line / Emergency Management

Diabetic Ketoacidosis (DKA) requires urgent hospital treatment.

Initial management includes:

  • Assess airway, breathing, and circulation
  • Intravenous fluid replacement
  • Insulin therapy
  • Potassium and electrolyte assessment/replacement
  • Frequent monitoring of glucose and ketones
  • Frequent monitoring of electrolytes and acid-base status
  • Identification and treatment of the precipitating cause

-Fluids

Intravenous isotonic crystalloid is generally started to restore circulating volume.

Fluid therapy should be individualized according to:

  • Hemodynamic status
  • Sodium concentration
  • Renal function
  • Cardiac function
  • Age
  • Risk of fluid overload

2. Definitive Treatment

The definitive treatment of Diabetic Ketoacidosis (DKA) is:

Fluid resuscitation + insulin + appropriate electrolyte replacement + treatment of the precipitating cause.

Insulin suppresses lipolysis and ketogenesis and allows resolution of the metabolic acidosis.

3. Medical Treatment

Insulin

  • Intravenous regular insulin is commonly used in moderate or severe DKA.
  • Insulin should generally continue until ketosis and metabolic acidosis have resolved, rather than stopping solely because glucose has normalized.

Potassium

Potassium must be monitored closely.

Although serum potassium may initially be normal or high, total body potassium is usually depleted because of urinary losses.

Potassium replacement is guided by the measured serum potassium level and renal function.

Complications

  • Hypoglycemia
  • Hypokalemia
  • Hyperkalemia
  • Cerebral edema
  • Acute kidney injury
  • Pulmonary edema/fluid overload
  • Electrolyte abnormalities
  • Shock
  • Coma
  • Death if untreated

Prognosis

With rapid recognition and appropriate treatment, most episodes of DKA resolve successfully.

Prognosis depends on:

  • Severity of acidosis
  • Degree of dehydration
  • Age
  • Renal and cardiovascular status
  • Presence of infection or other precipitating illness
  • Speed of treatment
  • Development of complications

Diabetic Ketoacidosis (DKA) can be fatal if untreated.

Key Points / Clinical Pearls

  • Diabetic Ketoacidosis (DKA) is a life-threatening diabetic emergency.
  • It results primarily from severe insulin deficiency and increased counter-regulatory hormones.
  • The key abnormalities are ketosis, metabolic acidosis, and hyperglycemia, although glucose may be only mildly elevated in euglycemic DKA.
  • DKA is most common in Type 1 Diabetes Mellitus, but it can also occur in Type 2 Diabetes Mellitus.
  • Common triggers include infection, missed insulin, acute illness, surgery, and myocardial infarction.
  • Classic symptoms include polyuria, polydipsia, nausea, vomiting, abdominal pain, and weakness.
  • Kussmaul respirations and fruity/acetone breath are characteristic clinical findings.
  • β-hydroxybutyrate is an important marker of ketonemia.
  • Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care. 2024;47(8):1257-1275. Diabetes Care .
  • American Diabetes Association Professional Practice Committee. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1). Diabetes Care .
  • Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care. 2009;32(7):1335-1343. Diabetes Care .
  • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Diabetes: Preventing Diabetes Problems . National Institutes of Health.
  • National Library of Medicine (NIH). Diabetic Ketoacidosis . StatPearls.