Diabetic ketoacidosis: was rarely fatal.

Clinical bottom line (level 2c)

  1. Diabetic ketoacidosis was rare in the general population, but occurred in around a tenth of patients with diabetes each year.
  2. The commonest causes were infection, treatment error, or classified as unknown.
  3. 3% of patients died after admission with DKA.
Snorgaard et al: Journal of Internal Medicine 1989; 226: 223-228
Expires October 2003

The study

Outcome study with objective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.

Setting: county, Denmark, 1978-9

161 patients (aged range 2 to 91 years; median 33, ?% male) with 175 episodes of diabetic ketoacidosis (defined as newly diagnosed or uncontrolled diabetes with heavy ketonuria (2+ or more) and plasma bicarbonate <21 mmol/l)



Outcomes studied:
  • cause: infection
  • cause: unknown
  • cause: treatment error
  • cause: affected by drugs or alcohol
  • cause: other endocrinological disorders
  • cause: other abdominal disorders
  • cause: myocardial infarction
  • cause: miscellaneous
  • cause: acute pancreatitis

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    cause: infection ? 66/175 38%
    (31% to 45%)
    cause: unknown ? 64/175 37%
    (29% to 44%)
    cause: treatment error ? 29/175 17%
    (11% to 22%)
    cause: affected by drugs or alcohol ? 16/175 9.1%
    (4.9% to 13%)
    cause: other endocrinological disorders ? 9/175 5.1%
    (1.9% to 8.4%)
    cause: other abdominal disorders ? 8/175 4.6%
    (1.5% to 7.7%)
    cause: myocardial infarction ? 6/175 3.4%
    (0.7% to 6.1%)
    cause: miscellaneous ? 6/175 3.4%
    (0.7% to 6.1%)
    cause: acute pancreatitis ? 3/175 1.7%
    (0.0% to 3.6%)

    • prevalence of DKA: 175/57496: 0.030% (95% CI: 0.026% to 0.035%)
    • prevalence of DKA in diabetic population: 175/1958: 8.9% (95% CI: 7.7% to 10%)
    • mortality: 3.4% (95% CI: 0.7% to 3.6%)

    Comments

    1. The size of the diabetic population was estimated using data from other Danish counties.
    2. This manuscript is one of the important documents showing that the traditional concept of diabetic ketoacidosis being the hallmark of Type 1 (permanent insulin deficient) diabetes is incorrect. It gives weight to the concept of diabetes being a continuum of metabolic disturbances ranging from absolute insulin deficiency to absolute insulin resistance.

    Citation

    1. Snorgaard O, Eskildsen PC, Vadstrup S, et al: Diabetic ketoacidosis in Denmark: epidemiology, incidence rates, precipitating factors and mortality rates. Journal of Internal Medicine 1989; 226: 223-228
    Search Terms: ketoacid* in Cochrane
    Contributor: Chris Ball and Clare Wotton, July 2000
    Reviewer: Jon Levine

    Clinical Question.
    Patient DKA
    Intervention or Exposure prevalence
    Outcome death, cause