title: Severe Ketoacidosis (pH ≤ 6.9) in Type 2 Diabetes: More Frequent and Less Ominous Than Previously Thought.
abstract: Diabetic ketoacidosis is a life-threatening acute metabolic complication of uncontrolled diabetes. Severe cases of DKA (pH ≤ 7.00, bicarbonate level ≤ 10.0, anion gap > 12, positive ketones, and altered mental status) are commonly encountered in patients with type 1 diabetes and are thought to carry an ominous prognosis. There is not enough information on the clinical course of severely acidotic type 2 diabetes (pH ≤ 6.9) patients with DKA, possibly because this condition is rarely seen in developed countries. In this series, we present 18 patients with type 2 diabetes, DKA, and a pH ≤ 6.9 that presented to a tertiary university hospital over the past 11 years. The objective was to describe their clinical characteristics, the triggering cause, and emphasis on treatment, evolution, and outcomes. The majority of the patients were female (61%). Mean age was 40.66 years (23-59). The patients had been first diagnosed with type 2 diabetes on average 5.27 ± 3.12 years before admission. Glutamic acid decarboxylase (GAD65) antibodies were negative in all patients. The origin of DKA could be attributed to two main causes: treatment omission in 8 (44.4%) patients and infections in 7 (38.8%) patients. The most common symptoms described were general malaise, dyspnea, altered mental status, and abdominal pain. Mean serum glucose on admission was 613.8 ± 114.5 mg/dL. Mean venous pH was 6.84 ± 0.03 with an anion gap of 30.3 ± 2.9 and a venous HCO3 level of 3.62 ± 1.35 mmol/L. All patients had acute renal failure on admission, with a mean serum creatinine of 1.57 ± 0.35 mg/dL compared to 0.55 ± 0.21 mg/dL at discharge. All patients received regular insulin infusion, aggressive fluid repletion, and 12 patients (66%) received bicarbonate infusion. Mean total insulin infusion dose was 181.7 ± 90.4 U (on average 0.14 ± 0.05 U/Kg/h). Mean time on infusion was 24.4 ± 12.6 hours. We recorded no mortality in this case series. Mean in-hospital stay was 5.0 ± 4.1 days. In conclusion, very severe DKA in type 2 diabetes is not uncommon in our population, shares many features with non-very-severe cases of DKA (bicarbonate therapy did not make a difference in mortality), and can be managed following standard published or institutional guidelines.
authors.affiliation: Division of Endocrinology, Internal Medicine Department, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, 64460 Monterrey, NL, Mexico ; Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: René
authors.initials: R
authors.lastname: Rodríguez-Gutiérrez
authors.affiliation: Department of Internal Medicine, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, 64460 Monterrey, NL, Mexico.
authors.forename: Carlos R
authors.initials: CR
authors.lastname: Cámara-Lemarroy
authors.affiliation: Department of Internal Medicine, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, 64460 Monterrey, NL, Mexico.
authors.forename: Dania L
authors.initials: DL
authors.lastname: Quintanilla-Flores
authors.affiliation: Department of Internal Medicine, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, 64460 Monterrey, NL, Mexico.
authors.forename: Emanuel I
authors.initials: EI
authors.lastname: González-Moreno
authors.affiliation: Department of Internal Medicine, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, 64460 Monterrey, NL, Mexico.
authors.forename: Juan Manuel
authors.initials: JM
authors.lastname: González-Chávez
authors.affiliation: Division of Endocrinology, Internal Medicine Department, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, 64460 Monterrey, NL, Mexico.
authors.forename: Fernando Javier
authors.initials: FJ
authors.lastname: Lavalle-González
authors.affiliation: Division of Endocrinology, Internal Medicine Department, University Hospital "Dr. José E. González", Autonomous University of Nuevo León, 64460 Monterrey, NL, Mexico.
authors.forename: Jose Gerardo
authors.initials: JG
authors.lastname: González-González
authors.affiliation: Latino Diabetes Initiative, Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA.
authors.forename: A Enrique
authors.initials: AE
authors.lastname: Caballero
mesh_terms: D000328:Adult; D003924:Diabetes Mellitus, Type 2 / Q000097:blood* / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D016883:Diabetic Ketoacidosis / Q000097:blood* / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D005260:Female; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007902:Length of Stay; D008297:Male; D008875:Middle Aged