Diabetic ketoacidosis (DKA) is a serious condition that can occur in people with both undiagnosed and known diabetes. It can be brought on by infection and other conditions.

Story by: David Steen Martin; Reviewed by Lisal J. Folsom, M.D., M.S. on December 28, 2023

Diabetic ketoacidosis (DKA) is a serious condition that can occur in people with diabetes, both undiagnosed and known diabetes. It can be brought on by a variety of contributors including lack of insulin, infection, alcohol or substance abuse, pancreatitis, acute coronary syndrome, a cerebrovascular accident or a pulmonary embolism.

Some of the first warning signs of diabetic ketoacidosis can include extreme thirst and frequent urination with high blood sugar levels.

These symptoms can quickly be followed by additional symptoms which may include rapid, deep breathing; a higher-than-normal heart rate; dry skin and dry mouth; fatigue; stomach pain; nausea; vomiting; a flushed face; headache or confusion; and muscle weakness.

“DKA occurs when a person has less insulin than their body needs to process the amount of sugar in the blood. Low insulin levels lead to DKA,” said Lisal J. Folsom, M.D., M.S., adult and pediatric endocrinologist with Wendy Novak Diabetes Institute, a part of Norton Healthcare and Norton Children’s Medical Group.

Insulin allows us to convert blood sugar into energy. Without enough insulin the body cannot produce enough energy from blood sugar. Because of this the blood sugar becomes very high, and the body needs to find a different source of energy.

As a backup, the liver turns fat into ketones which supply some energy, a process called ketosis. Ketones are a less effective energy source, but they can less effectively fuel our cells. Ketones are filtered by the kidneys and leave the body through urination.

Ketosis is not always dangerous, and it’s not always the result of insulin deficiency. Ketosis can occur during sleep, exercise, or fasting.

DKA occurs when a person doesn’t have enough insulin to convert blood sugar into energy, and too many ketones build up in the blood. High ketone levels can make your blood too acidic, which is dangerous.

As a result of blood becoming acidic, several important electrolytes and minerals, including potassium and magnesium, are lost from the body through urine. It’s important to get these back to normal levels so the heart maintains a proper rhythm. Abnormal levels of potassium and magnesium can cause cardiac arrythmias.

“Diabetic ketoacidosis is potentially life-threatening, so it’s important to get medical help right away if you are experiencing the warning signs,” Dr. Folsom said.

Diagnosis and treatment

Diagnosis of DKA involves blood tests to measure acid levels, blood sugar, and ketones.

Treatment for DKA is complex, and patients with DKA need to be admitted to the hospital, often the intensive care unit, for careful monitoring for serious side effects. In general, patients with DKA are very dehydrated and have a fluid deficit of 5% to 10% of their body weight. These fluids need to be replaced with intravenous (IV) fluids.

A person with DKA requires treatment with insulin to allow the body to resume making energy from glucose rather than ketones. This fuels the cells and prevents more ketones from being produced.

Other rare but serious complications

One serious complication of DKA is cerebral edema, or swelling of the brain. This can cause a temporary change in mental status or become much more serious and even result in death.

DKA also can cause rhabdomyolysis, sometimes called rhabdo, which occurs when damaged muscle tissues release proteins and electrolytes into the blood. This can cause damage to the heart and kidneys, potentially resulting in permanent disability or death.

In addition, malignant hyperthermia can occur with DKA. Malignant hyperthermia can cause symptoms that include a dangerously high temperature, rigid muscles, muscle spasms and a rapid heart rate resulting in heart damage.