Ketoacidosis is a variant of metabolic acidosis. It manifests primarily in the setting of diabetes mellitus when there is a total insulin deficiency.
What is ketoacidosis?
Ketoacidosis represents a form of metabolic acidosis. In most cases, it occurs in diabetes mellitus (diabetes) type 1. In this case, there is an absolute lack of insulin and there is a severe metabolic derailment. The typical features of diabetic ketoacidosis (hyperacidity) include a high concentration of ketone bodies within the blood and elevated blood glucose levels. Because ketoacidosis is an emergency, intensive medical therapy must be initiated immediately.
Causes
Usually, ketoacidosis forms an overacidification of metabolism (acidosis) due to ketone bodies such as acetone. The metabolic derailment is caused by the accumulation of organic acids such as ß-hydroxybutyric acid and acetoacetic acid in the blood. As a result, its pH value is decreased. It is almost always diabetic ketoacidosis, the cause of which is a prolonged deficiency of insulin. The insulin deficiency results in the body’s cells no longer being able to obtain glucose from the blood. Thus, it is insulin that enables the transporter Glut 4 to move into the membranes of the cells. However, in order for glucose to be absorbed into a cell, this transporter must be present. In the further course it comes to an insufficiently covered energy balance of the body cells. The lack of energy is indicated to the brain by the cells. This leads to the release of adrenaline and noradrenaline as well as other insulin antagonists. This results in increased fat breakdown in the adipose tissues. The fat that is released is converted by the liver into ketone bodies and released into the blood. The lack of insulin in turn leads to increased fat breakdown in the liver, resulting in the formation of the acetyl-coenzyme acetyl-CoA. This then gives rise to acetoacetate. This is a salt of acetoacetic acid. Acetoacetate functions as an energy supplier within the tissue in the context of starvation metabolism. In most cases, ketoacidosis is caused by catabolic metabolism due to insulin deficiency. This causes organic acids to accumulate in the blood. Another typical trigger is a marked increase in ß-hydroxybutyric acid in the blood due to heavy alcohol consumption. Physicians then speak of alcoholic ketoacidosis. Gluconeogenesis is thus inhibited by the alcohol. The same applies to the oxidation of free fatty acids within the liver. Other possible causes of ketoacidosis include SCOT syndrome, in which there is a congenital succinyl-CoA-acetoacetate transferase deficiency, and various hereditary diseases.
Symptoms, complaints, and signs
The typical features of diabetic ketoacidosis include the occurrence of high blood glucose levels. As a result, affected individuals suffer from fatigue, frequent urination, loss of appetite, and thirst. In addition, the symptoms of hyperacidity appear. These primarily include an odor of acetone in the breath, deep breathing, also called kissing mouth breathing, abdominal pain, nausea and vomiting. There are also changes in consciousness, loss of consciousness, or even diabetic coma. Furthermore, there is a risk of dehydration of the body. If no medical treatment takes place, the patient may die. People suffering from type 1 diabetes mellitus are particularly at risk for ketoacidosis. If, for example, an insulin injection is forgotten, this quickly results in an insulin deficiency, which is manifested by symptoms. There is also an increased risk in the case of infections accompanied by fever. If the metabolism collapses, there is a risk of coma and circulatory failure.
Diagnosis and course of the disease
Because ketoacidosis is a medical emergency, the patient must receive immediate medical attention and be admitted to a hospital. There, the physician’s diagnosis takes place. This doctor measures the blood glucose level as well as the ketone bodies within the urine. A blood sample is also taken from the wrist to check the pH value as well as the blood gases. Furthermore, salts in the blood such as sodium or potassium are measured and signs of infection are looked for. In the worst case, ketoacidosis takes a fatal course.However, recovery of the patient is possible if the physician recognizes the symptoms at the right time. Without proper treatment, permanent damage to the brain, heart and kidneys is possible.
Complications
Ketoacidosis usually causes a very severe lack of insulin. This can have a very negative impact on the life of the affected person and thereby usually leads to severe symptoms and complications. Most of those affected suffer from frequent urination, fatigue and exhaustion. In most cases, the patient’s ability to cope with stress also decreases enormously. The loss of appetite can lead to underweight and also to deficiency symptoms. It is not uncommon for patients to suffer from abdominal pain and nausea and to vomit frequently. The daily life of the affected person is severely restricted by the ketoacidosis. In the worst case, loss of consciousness or coma may occur. The affected person suffers from fever and a weakened immune system. This can lead to inflammations and infections throughout the body in a simplified manner. Likewise, the affected person may collapse and injure himself in a fall. Ketoacidosis is usually treated with the help of medication. Complications occur when treatment is not initiated in time. Usually, life expectancy is not reduced in this disease.
When should you go to the doctor?
Diabetes patients should consult their doctor if they show signs of ketoacidosis. Symptoms such as loss of appetite and thirst, frequent urination, and fatigue always require evaluation by a medical professional. Anyone who notices signs such as abdominal pain, bad breath or changes in consciousness should consult a doctor. If a severe fever also occurs, an immediate visit to the doctor is indicated. Ketoacidosis can be treated with medication if it is detected early enough. Therefore, a doctor should be consulted at the first signs of metabolic acidosis. People suffering from an infection or type 1 diabetes mellitus are particularly susceptible to developing ketoacidosis. Anyone belonging to these risk groups should have the above-mentioned symptoms clarified by a physician immediately in order to avoid serious complications. If further symptoms occur or the above-mentioned complaints suddenly increase in intensity, medical advice is required. The right place to turn to is a general practitioner or an internist. In the event of a medical emergency, the sufferer must be taken to a hospital immediately.
Treatment and therapy
Treatment of ketoacidosis takes place in the hospital. The focus is on addressing the cause of the metabolic derailment. The most important therapeutic measure is intravenous administration of insulin and fluid. In addition, larger amounts of potassium must be administered promptly to counteract hypokalemia. If a bacterial infection is present, the administration of antibiotics may also be useful. In the course of ketoacidosis therapy, intensive care or emergency medical treatment measures are also taken to maintain vital functions. Furthermore, laboratory monitoring of the patient must be performed so that possible life-threatening changes can be detected in time. Rapid intervention is particularly necessary in the event of severe deviations in potassium levels or blood glucose levels. In the case of a severely elevated ketone body level, additional bicarbonate can be administered if necessary.
Outlook and prognosis
If treatment is not given or is inadequate, ketoacidosis can be fatal. Statistically, 5% to 15% of patients die from ketoacidotic coma. Life-threatening symptoms such as unconsciousness, dehydration and breathing difficulties may occur. If inadequately treated, there is a risk of hypokalemia. Furthermore, lactate acidosis may also develop as a result of ketoacidosis. Other common causes of death as a result of ketoacidosis are cardiovascular failure and infection. However, if ketoacidosis is detected in time so that prompt treatment can be given, the outlook is good. A rapid response time, ideally within hours of the onset of the first symptoms, reduces the risk of further deterioration. The temporary shortness of breath that can occur with ketoacidosis will resolve completely with successful treatment. A rare risk that exists despite successful treatment is the formation of cerebral edema.In particular, too rapid normalization of blood glucose is considered a risk factor. Neurological sequelae are possible as a result. About 1 % of patients with ketoacidosis are affected by this complication. Children and adolescents are particularly at risk. It should not be ignored, however, that insulin treatment will still be necessary to prevent further ketoacidosis. The underlying disease may otherwise lead to ketoacidosis again. With proper continued treatment, the prospects for full recovery are very good.
Prevention
To prevent ketoacidosis from occurring in the first place, diabetics must have their blood glucose levels well controlled. Type 1 diabetics are advised to always carry an emergency dose of insulin. In case of infection, it may be advisable to increase the insulin dose, which should be done in consultation with the physician.
Follow-up
The affected person usually has very few measures of aftercare available in ketoacidosis. However, a diagnosis and subsequent treatment should be initiated at an early stage to prevent the further occurrence of symptoms and complications. As a rule, ketoacidosis cannot be cured on its own, so that the person affected by this disease is in any case dependent on treatment by a doctor. Most of the affected persons have to take various medications and antibiotics. The doctor’s instructions should always be followed so that the symptoms can be completely alleviated. In case of any uncertainties or questions, a doctor should always be consulted first in order to prevent further worsening of the symptoms. Various supplements can also be taken with the diet to speed up the healing process. When taking antibiotics, it should be noted that they should not be taken together with alcohol. Usually, after the treatment of ketoacidosis, no further measures of aftercare are necessary. In this case, the disease does not usually have a negative effect on the life expectancy of the affected person.
What you can do yourself
The most important self-measure is to prevent the development of diabetic ketoacidosis. To do this, blood glucose must be properly adjusted and regularly checked by a doctor. The values should also be measured if you feel unwell, and if necessary a specialist should be consulted. Ketone bodies in the urine can be determined by means of special measuring strips from the pharmacy. If a ketoacidosis has already developed, it must be treated as an inpatient in any case. Various measures support the treatment and alleviate the individual symptoms. First, the body must be supplied with sufficient fluids and minerals. In the acute phase of the disease, the diet should consist of high-salt foods, herbal teas and water. In order to stabilize blood sugar, sweet foods may be consumed in consultation with the physician. The patient should also rest and take a sick leave for a few days. Strenuous physical activity should be avoided as far as possible. Light gymnastic exercises that get the circulation going and strengthen the immune system are permitted. Regular visits to the doctor are also part of aftercare. The physician must ensure that blood sugar remains stable and that no further complications occur.
