Диабетический кетоацидоз: причины, симптомы и лечение.

DKA happens most often in those with type 1 diabetes but can also occur in those with other types of diabetes under certain circumstances. DKA is typically diagnosed when testing finds high blood sugar, low blood pH and keto acids in either the blood or urine. Each year, about 4% of type 1 diabetics in the United Kingdom develop DKA, versus 25% of type 1 diabetics in Malaysia. With adequate and timely treatment, the risk of death is between <1% and 5%. The condition remained almost universally fatal until the discovery of insulin in the 1920s; by the 1930s, mortality had fallen to 29 percent, The entity of cerebral edema due to DKA was described in 1936 by a team of doctors from Philadelphia. Numerous research studies since the 1950s have focused on the ideal treatment for diabetic ketoacidosis. A significant proportion of these studies have been conducted at the University of Tennessee Health Science Center and Emory University School of Medicine.) insulin, phosphate supplementation, need for a loading dose of insulin, and the appropriateness of using bicarbonate therapy in moderate DKA. In severe DKA, breathing becomes rapid and of a deep, gasping character, called "Kussmaul breathing". The abdomen may be tender to the point that a serious abdominal condition may be suspected, such as acute pancreatitis, appendicitis or gastrointestinal perforation. If the dehydration is profound enough to cause a decrease in the circulating blood volume, a rapid heart rate and low blood pressure may be observed. Often, a "ketotic" odor is present, which is often described as "fruity" or "like pear drops". If Kussmaul respiration is present, this is reflected in an increased respiratory rate. It occurs in about 1 out of 100 children with DKA and more rarely occurs in adults.

DKA most frequently occurs in those who know that they have diabetes, but it may also be the first presentation in someone who has not previously been known to be diabetic. There is often a particular underlying problem that has led to the DKA episode; this may be intercurrent illness (pneumonia, influenza, gastroenteritis, a urinary tract infection), pregnancy, inadequate insulin administration (e. g. defective insulin pen device), myocardial infarction (heart attack), stroke or the use of cocaine. Young people with recurrent episodes of DKA may have an underlying eating disorder, or may be using insufficient insulin for fear that it will cause weight gain. Their condition is then labeled "ketosis prone type 2 diabetes". Drugs in the gliflozin class (SGLT2 inhibitors), which are generally used for type 2 diabetes, have been associated with cases of diabetic ketoacidosis where the blood sugars may not be significantly elevated ("euglycemic DKA"). While this is a relatively uncommon adverse event, it is thought to be more common if someone receiving an SGLT2 inhibitor who is also receiving insulin has reduced or missed insulin doses. Furthermore, it can be triggered by severe acute illness, dehydration, extensive exercise, surgery, low carbohydrate diets, or excessive alcohol intake. SGLT2 inhibitors should be stopped before surgery and only recommenced when it is safe to do so. SGLT2 inhibitors may be used in people with type 1 diabetes, but the possibility of ketoacidosis requires specific risk management. Specifically, they should not be used if someone is also using a low carbohydrate or ketogenic diet.

Diabetic ketoacidosis arises because of a lack of insulin in the body. The lack of insulin and corresponding elevation of glucagon leads to increased release of glucose by the liver (a process that is normally suppressed by insulin) from glycogen via glycogenolysis and also through gluconeogenesis. High glucose levels spill over into the urine, taking water and solutes (such as sodium and potassium) along with it in a process known as osmotic diuresis. DKA is common in type 1 diabetes as this form of diabetes is associated with an absolute lack of insulin production by the islets of Langerhans. In type 2 diabetes, insulin production is present but is insufficient to meet the body's requirements as a result of end organ insulin resistance. Usually, these amounts of insulin are sufficient to suppress ketogenesis. If DKA occurs in someone with type 2 diabetes, their condition is called "ketosis prone type 2 diabetes". Cerebral edema, which is the most dangerous DKA complication, is probably the result of a number of factors. Some authorities suggest that it is the result of overvigorous fluid replacement, but the complication may develop before treatment has been commenced. and went through several other descriptive names (such as "idiopathic type 1 diabetes", "Flatbush diabetes", "atypical diabetes" and "type 1.5 diabetes") before the current terminology of "ketosis prone type 2 diabetes" was adopted. There is a link with G6PD deficiency.

Diabetic ketoacidosis may be diagnosed when the combination of hyperglycemia (high blood sugars), ketones in the blood or on urinalysis and acidosis are demonstrated. At very high levels, capillary blood ketone measurement becomes imprecise. In addition to the above, blood samples are usually taken to measure urea and creatinine (measures of kidney function, which may be impaired in DKA as a result of dehydration) and electrolytes. Furthermore, markers of infection (complete blood count, C reactive protein) and acute pancreatitis (amylase and lipase) may be measured. Given the need to exclude infection, chest radiography and urinalysis are usually performed. Slower rehydration based on calculated water and sodium shortage may be possible if the dehydration is moderate, and again saline is the recommended fluid. There have been a few small trials looking at balanced fluids with few differences. In general, insulin is given at 0.1 units/kg per hour to reduce blood sugars and suppress ketone production. Guidelines differ as to which dose to use when blood sugar levels start falling; American guidelines recommend reducing the dose of insulin once glucose falls below 16.6 mmol/L (300 mg/dL) Lower socio‐economic status and higher area‐level deprivation are associated with an increased risk of diabetic ketoacidosis in people with diabetes mellitus type 1. Previously considered universally fatal, the risk of death with adequate and timely treatment is between <1% and 5%. Rates of cerebral edema in US children with DKA have risen from 0.4% in 2002 to 0.7% in 2012. Between 2 and 5 out of 10 children who develop brain swelling will die as a result.