What is ketoacidosis?

What is ketoacidosis?

Ketoacidosis is a severe, life-threatening metabolic imbalance that occurs primarily in people with diabetes mellitus (diabetic ketoacidosis). Ketoacidosis can manifest itself through a variety of symptoms, ranging from so-called “Kussmaul breathing” to a coma. Here, you can learn precisely what ketoacidosis is, how it develops and what treatment options are available.

What does ketoacidosis mean?

The word ketoacidosis is a combination of the terms acidosis and ketosis.

Acidosis describes an acidic metabolic state of the body; the pH value of the blood is in the acidic range (<7.35). The cause is the predominance of acidic substances in the blood, such as carbon dioxide (CO2) and hydrogen ions (H + ).

Ketosis is an excess of so-called ketone bodies in the blood. These are sugar substitutes that the body can produce itself and have acidic properties.

Taken together, ketoacidosis means that there are so many acidic ketone bodies in the blood that the pH of the blood has dropped into the acidic range. In contrast to respiratory acidosis, which is caused by breathing problems, ketoacidosis belongs to metabolic acidosis (metabolic acidosis).


Why does ketoacidosis develop?

The body forms the ketone bodies in the liver as substitutes for sugar particles ( carbohydrates ), which it needs as an energy source for all its functions. Typically, ketone bodies are formed as an intermediate product of fat metabolism and are always found in small amounts in the blood.

However, if not enough sugar, more fatty acids are broken into ketone bodies and released into the blood. The production of a sugar alternative is a sensible measure by the body to provide us with the energy we need despite a lack of sugar. However, problems arise due to the acidic properties of the ketone bodies.

For example, a sugar deficiency that can trigger ketoacidosis typically occurs in diabetes mellitus, starvation, and alcoholism.

Ketoacidosis in type 1 and type 2 diabetes

The occurrence of diabetic ketoacidosis is primarily associated with poor blood sugar control. Metabolic derailment occurs in both type 1 diabetes and type 2 diabetes but is more common in type 1 diabetes. Regular cannabis use also appears to increase the risk of developing ketoacidosis in type 1 diabetes.


Diabetic ketoacidosis due to administration of SGLT-2 inhibitors

In rare cases, therapy with SGLT-2 inhibitors can also trigger atypical diabetic ketoacidosis in the sense of a life-threatening, undesirable drug effect. This was the result of an evaluation of various specialist publications.

Physicians see a combination of carbohydrate reduction, reduction in insulin dose and continued administration of SGLT-2 inhibitors as the “probable trigger” of diabetic ketoacidosis. Diabetic ketoacidosis has also been observed increasingly as a result of dehydration, illness, intensive exercise and excessive alcohol consumption.

For the prevention of SGLT-2-associated diabetic ketoacidosis, it is recommended not to reduce insulin doses inappropriately. If diabetic ketoacidosis occurs, administration of SGLT-2 inhibitors should be stopped.

Based on an observed case, doctors from Switzerland also recommend that patients with type 1 diabetes should at least not be treated with SGLT-2 inhibitors such as empagliflozin outside of study scenarios.

Symptoms of ketoacidosis

Symptoms from ketoacidosis usually develop slowly and over days. Symptoms may include abdominal pain, vomiting and fever.

In the case of diabetic ketoacidosis, a feverish infection often precedes it. Those affected feel intense thirst with frequent urination at the same time.

Deep breathing, the so-called “Kussmaul breathing”, is typical of ketoacidosis since the body tries to exhale the acidic substances when the metabolism is acidic. In addition, the breath can smell acetone and, therefore, sweet and a little like rotten fruit.

Furthermore, equalizing currents of blood salts (electrolytes) occur. If the electrolyte ratios are out of balance, cardiac arrhythmia can occur, as well as kidney dysfunction and water retention, which are particularly dangerous for the brain (cerebral oedema). In the final stages of ketoacidosis, there is a risk of shock and coma.

Coma in ketoacidosis

Diabetic ketoacidosis is the leading cause of death in children and adolescents with type 1 diabetes.

The hormone insulin transports the sugar molecules into the cells, where they are needed as energy suppliers. If no insulin is available, the sugar molecules remain in the blood (hyperglycaemia) and are absent from the cells.

The ketone bodies are formed to compensate. The resulting hyperacidity of the blood can lead to impaired consciousness, ranging from fainting to a coma.

A coma associated with ketoacidosis is called “ketoacidosis coma” and typically occurs in people with type 1 diabetes mellitus (“coma diabetic”). In the case of type 1, there is a complete lack of insulin, in contrast to type 2 diabetes mellitus, which can still produce a little insulin.


Therapy of ketoacidosis

Treatment for ketoacidosis depends on how far the disease has progressed. If the person concerned is in a coma, there is an emergency and intensive medical measures must be taken immediately in the hospital. Respiration and circulation must be secured, and the internal organs must be protected from failure.

In general, the treatment of diabetic ketoacidosis consists of measures for rehydration, balancing of the electrolyte balance and the administration of insulin.

It is always essential to have a sufficient supply of fluids via intravenous access. If there is pronounced acidosis and a meagre pH value in the blood, compensating substances can be given to buffer the acidic metabolic situation. To rebalance the electrolyte balance, sodium or potassium substitution is often necessary.

In the case of diabetic ketoacidosis, insulin is given to help transport the sugar molecules into the cells. People with diabetes should be informed by their doctor about the danger of ketoacidosis and receive recommendations for the correct behaviour at the first signs of metabolic imbalance.

Prevention of diabetic ketoacidosis

The most critical measure to prevent diabetic ketoacidosis is early treatment of high blood sugar levels. People with diabetes should also be informed by medical staff about how to act correctly in the event of elevated levels.

To prevent the complications of diabetic ketoacidosis in type 1 diabetics in childhood and adolescence, there are the following options:

  • Education:  Studies have shown that the frequency of diabetic ketoacidosis falls when those affected and their parents are aware of the typical symptoms of their diabetes.
  • Autoantibody screening: The risk of developing type 1 diabetes increases with the number of antibodies present. If you know you are at risk, you can take countermeasures before the symptoms appear. Early knowledge of an increased risk of disease and appropriate education can also reduce the likelihood of diabetic ketoacidosis.
  • Vaccinations: Coxsackie B and rotavirus vaccinations can also be considered.


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